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Defensive Charting For Nurses Course

Defensive Charting For Nurses Course - When documentation becomes your defense; This defense is built carefully, meticulously, with detailed paper trails beginning from the moment the nurse first sees a patient. Chart any procedures you do and patient response, chart pain and pain meds. This class will engage both experienced and n ewer nurses. Specializes in infusion nursing, home health infusion. Steps nurses can take to improve their charting and reduce their liability whether you are an experienced nurse or recent grad, documentation can be challenging. Describe documentation strategies for challenging situations. ~ legal lingo ~ general documentation tips ~ narrative note writing ~ incident report writing ~ crisis standards of care Armed with a fundamental understanding of this information, clinicians will be able to meet documentation expectations. The who, what, when, where, why and how;

When documenting, record only information and behavior you observe. Describe two documentation strategies to reduce liability exposure. Explain the multiple purposes of documentation and documentation fundamentals. Examples of good and bad charting; Step into the realm of comprehensive charting with advocate maggie for an unparalleled perspective. Facilitated by registered nurses with first hand clinical experience, this ½ day blended learning course allows attendees to gain theoretical and practical pressure area care knowledge. This course is designed to give learners an overview of the best documentation practices for anyone in healthcare who contributes to a client’s medical record. You’ll leave this course with a broader understanding of what effective charting looks like, as well as ineffective charting. Here is some information that can assist with improving your charting and reducing liability risks: ~ legal lingo ~ general documentation tips ~ narrative note writing ~ incident report writing ~ crisis standards of care

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You’ll Leave This Course With A Broader Understanding Of What Effective Charting Looks Like, As Well As Ineffective Charting.

~ legal lingo ~ general documentation tips ~ narrative note writing ~ incident report writing ~ crisis standards of care It also helps nurses meet standards of professional practice. Tips for passing medicare audits, charting incident reports and writing physicians’ orders accurately will all be discussed. This course will update nurses on the requirements of medical record documentation as well as professional, responsible documentation strategies.

One Tool Especially Suited For Defensive Documentation Is The Acronym Fact, Which Stands For Factual, Accurate, Complete, And Timely.

The course will examine real examples of patient care and use lessons learned to vastly improve incident reporting and. The purpose of this module is to provide an overview of nursing documentation, outlining the professional standards, most common documentation errors, and legal risks of incomplete nursing documentation amidst evolving technology and reliance on electronic medical records. This defense is built carefully, meticulously, with detailed paper trails beginning from the moment the nurse first sees a patient. Cynthia will share her knowledge of how documentation is used in the legal arena with examples of common documentation pitfalls.

The Importance Of Creating A Clearly Defined Plan Of Care With Interprofessional Goals And Strategies Is Critical To Ensuring Documentation Is Defensible To.

Specializes in infusion nursing, home health infusion. At its core, documentation should provide a nurse with an indisputable defense against malpractice. Nurses play a vital role in improving the safety and quality of patient car not only in the hospital or ambulatory treatment facility but also of community based care and the care performed by family members nurses need know what proven Join nursing colleagues for an interactive class discussing defensive documentation.

Avoid Value Judgments, Bias, Labels, And Subjective Opinions.

The concepts of skilled, reasonable, and necessary will be articulated in terms nurses and therapists will understand. The main thing is to stick to the facts only the facts, don't offer your own thoughts on things or try to write a story. Learn to chart like your license depends on it! Armed with a fundamental understanding of this information, clinicians will be able to meet documentation expectations.

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