Professional Documentation Safe Effective and Legal

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Michael Reese Hospital and Medical Center MRHMC in Chicago Illinois At MRHMC she served on. the faculty and administrative staff of the Michael Reese School of Nursing directed the departments of. Nursing Education Evaluation and Research Critical Care Nursing and Emergency Department. Nursing She developed a hospital wide education department to serve 3 500 staff members In. addition to mandated educational programming specific initiatives during her tenure in the education. leadership role included management development unit based quality improvement and preceptor. development, Bette earned her BSN at Syracuse University in Syracuse New York and her MSN and PhD in. Educational Psychology at Loyola University Chicago Chicago Illinois. Disclaimer, RN com strives to keep its content fair and unbiased. The author s planning committee and reviewers have no conflicts of interest in relation to this course. Conflict of Interest is defined as circumstances a conflict of interest that an individual may have which. could possibly affect Education content about products or services of a commercial interest with which. he she has a financial relationship, There is no commercial support being used for this course Participants are advised that the accredited. status of RN com does not imply endorsement by the provider or ANCC of any commercial products. mentioned in this course, There is no off label usage of drugs or products discussed in this course. You may find that both generic and trade names are used in courses produced by RN com The use of. trade names does not indicate any preference of one trade named agent or company over another. Trade names are provided to enhance recognition of agents described in the course. Note All dosages given are for adults unless otherwise stated The information on medications. contained in this course is not meant to be prescriptive or all encompassing You are encouraged to. consult with physicians and pharmacists about all medication issues for your patients. The purpose of this course is to present key topics related to nursing documentation Nursing. documentation is a critical component in high quality patient care and safe effective nursing practice. that is legally and ethically sound,Learning Objectives.
After successful completion of this course you will be able to. 1 State the goals of documentation, 2 Explain the role of organizational policies and procedures in guiding documentation. 3 State the purpose of the patient s medical record. 4 Identify standards and principles of documentation as described by the American Nurses. Association ANA,5 Explain nursing documentation implications of. Centers for Medicare and Medicaid CMS regulations regarding Hospital Acquired. Conditions HACs, National Quality Forum NQF Serious Reportable Events SREs also known as Never. Events and,Material protected by Copyright,Joint Commission Requirements. 6 Identify documentation practices that validate safe effective and high quality patient centered. 7 Identify documentation practices that create legal and professional risks. 8 Explain and give examples of the key elements of medical malpractice. 9 Identify characteristics of nursing documentation that support a legal defense of nursing actions. 10 Identify actions that constitute defamation, 11 Explain documentation implications of the Health Insurance Portability and Accountability Act of.
1996 HIPAA, 12 Identify employment and licensure implications of nursing documentation. 13 Explain nursing documentation requirements for specific aspects of care including critical. diagnostic results medications non conforming patient behavior pain patient and family. involvement in care restraints and prevention of falls infections pressure ulcers and suicide. 14 Describe recommended documentation practices concerning communication with the patient s. provider and provider orders such as questioning orders and receiving verbal orders. 15 Give examples of important nursing documentation in addition to the patient s medical record. which might establish the nurse s competencies presence responsibilities and compliance with. policies and procedures, 16 Identify precautions to observe when using electronic documentation. 17 Identify crucial elements of documenting situations that require special documentation practices. including consents unusual events patient s personal property and 24 hour record checks. 18 Identify selected specialty specific documentation issues. Introduction, The most important role of documentation is to assure high quality patient care This course presents. universal documentation principles which apply whether your organization relies heavily upon. electronic documentation paper based documentation or a combination of the two systems. You will find that the principles are not new However lapses in applying these principles create. problems when documentation is presented as evidence to defend against allegations of malpractice. negligence or failure to meet standards of care, By concentrating on the principles of documentation you will document the quality care you provide and. fulfill your responsibilities You will also reduce the risks of a lawsuit against you the organization at. which you are working and any other employer such as a temporary staffing agency. One of the cardinal principles of legally defensible documentation is strict adherence to. organizational policy and procedure P P Know the P P guidelines of the organization and the. state in which you practice,Make Documentation Your Ally.
Documentation,Assists in organizing your thoughts, Aids in identifying problem areas planning and evaluating care. Offers a means to communicate with other team members. Provides a way to take credit for what you have observed and done. Ensures reimbursement,Material protected by Copyright. Affords legal protection to you and your employer, May be used in research to support decision analysis and in quality improvement. Lippincott Williams Wilkins 2008, Nursing documentation also aids careful assessment and guides nursing action by providing. assessment tools and tools for recording evidence based procedures such as practice bundles. P P Your Best Friend or Worst Enemy, Your organization has established P P that incorporate federal state and local laws reimbursement.
requirements accreditation standards and standards and recommendations of various healthcare. quality organizations You are accountable not only for adhering to P P but also for documenting. compliance Your documentation serves as evidence of your compliance. New policies procedures and guidelines develop continuously in response to clinical advances. federal and state legal mandates and requirements of accrediting bodies. Reduce your risk for legal and professional exposure Make it your mission to orient yourself thoroughly. in new situations and continuously update your knowledge of P P and guidelines. When you are new to the unit, Review the key points of the information presented to you in orientation Ask yourself how practices. in this organization differ from your previous position Validate your assumptions about whether. previous expectations apply in this setting,During your first shift on the unit. Make a point of reviewing two or more medical records Pay particular attention to nursing. documentation and flow sheets Are the instructions clear If not ask a staff member to clarify. If and when you float, Make it a priority to familiarize yourself with documentation expectations unique to the unit to which. you have floated,Key Policies and Procedures, Failure to follow P P is among the most frequent allegations against nurses in lawsuits Croke 2003. Know key policies and where to locate the rest Before you begin your first shift be sure you know the. How to access P P and guidelines whether paper or computer based. Physical location and or intranet access of all key nursing manuals for which you have. responsibility, Chain of command for addressing patient care issues.
All the medical record forms to be completed, How to document an unexpected event in the patient s record and on any other form. Location of safety disaster manuals and infection control procedures. How to document issues that arise with friends and families of patients. Forms to be completed for discharge,System for providing discharge instructions. Material protected by Copyright, This key information will equip you to document appropriately and minimize your exposure to litigation. It also provides for the best communication between you and other staff members about the condition. of your patients Do not guess about expectations and standards Know where to find the P P. Recognize that in any lawsuit accreditation survey or disciplinary action organizational P P. will be upheld as the standard against which your actions are judged. Policies with Documentation Implications, All organizational P P are important From the legal accreditation and regulatory perspective. documentation validates or proves compliance with P P Certain policies have particular implications. for documentation Some of these include,Abbreviations Do Not Use List.
Admission Transfer and Discharge,Advance Directives. Patient Assessment,Cardiac Respiratory Resuscitation. Chain of Command,Crash Carts,Hazardous Materials,Incident Reports. Infection Control and prevention of specific infections such as catheter associated urinary tract. infections CAUTI central line associated bloodstream infections CLABSI and. ventilator associated pneumonia VAP,Medication Administration. Medication Reconciliation,Pain Management,Patient Fall Prevention.
Rapid Response Team or other system to respond quickly to deteriorating patient condition. Restraints,Safe Medical Devices,Sentinel Events,Suspected Abuse. Workplace Violence,The Patient s Medical Record, If you think of the medical record first and foremost as clinical communication that you documented. carefully you need not panic if the court subpoenas it However if you think only of legal implications or. Material protected by Copyright, document to protect yourself your part of the medical record will sound self serving and defensive. Such documentation tends to have a negative impact on a judge and jury Lippincott Williams. Wilkins 2008, The medical record also called the patient s record or the chart serves four major purposes The. 1 Acts as a vehicle for communication among members of the healthcare team. 2 Documents compliance with standards of care and standards of various accrediting organizations. such as TJC and the state health department, 3 Documents compliance with standards that must be met for reimbursement by a third party payor.
such as Medicare Medicaid or another insurance carrier. 4 Documents that patient care meets safe effective and legal requirements. Common Charting Errors, Common charting mistakes to avoid include the following. 1 Failing to record pertinent health or drug information. 2 Failing to record nursing actions, 3 Failing to record that medications have been given. 4 Recording in the wrong patient s medical record,5 Failing to document a discontinued medication. 6 Failing to record drug reactions or changes in the patient s condition. 7 Transcribing orders improperly or transcribing improper orders. 8 Writing illegible or incomplete records,Nurses Service Organization 2008 pp 4 5. Did you know, Judges juries accreditation surveyors supervisors and other interested parties take the position.
If it wasn t documented it wasn t done,Documentation Standards. Healthcare organizations establish documentation policies based upon standards set by organizations. American Nurses Association ANA publishes the Scope and Standards of Practice Nursing. and ANA s Principles for Nursing Documentation, Nursing Specialty Organizations publish standards of practice and competencies. Center for Medicare and Medicaid CMS when processing claims requires evidence that. certain infections and injuries for which reimbursement is sought were not acquired in the. healthcare organization, National Quality Forum NQF has identified a list of 29 Serious Reportable Events SREs also. known as Never Events, The Joint Commission TJC develops Accreditation Standards and National Patient Safety. Material protected by Copyright,Goals NPSG,State Nurse Practice Acts.
Federal State and Private Insurance Reimbursement Guidelines. All aspects of care that standards mandate must be documented as evidence that care was provided. All sources of documentation standards and requirements emphasize. Ongoing assessment, Patient teaching including the patient s response to teaching and indication that the patient has. Response to all medications treatments and interventions. Relevant statements made by the patient, Your organization s P P are the standard against which your practice is judged in a court of. law or in any disciplinary proceeding,Not Documented Not Done. Be specific avoid general terms and vague expressions. Read and act upon progress notes of the previous shift. Document complete assessment data even when not related to the chief complaint or patient need. you are addressing For example if the patient complains of constipation while you changing a. dressing on a leg ulcer you will certainly assess the patient with respect to constipation Assure that. electronic documentation paper based documentation or a combination of the two systems You will find that the principles are not new However lapses in applying these principles create problems when documentation is presented as evidence to defend against allegations of malpractice negligence or failure to meet standards of care

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