Documentation: Legal Issues & Practice Pearls

By Carol M. Stock, JD, MN, RN

Workshop Outline 

• Do you spend too much time charting? 

• Have you ever sent or received a mis-directed fax or email and wondered what to do?

• Are you unsure about how much follow-up is enough?

• Are you confused over how to use email safely in practice?

• Do you skip documenting patient telephone advice?

• Are you puzzled about patient release of records?

• Is your patient teaching documentation vague and unclear?

• Are you perplexed over the legalities of EMR's (Electronic Medical Records)

• Are you unclear about HIPAA Privacy Standards in practice?

If you answered "Yes" to any of these, you should attend this seminar. 

This interactive one-day seminar focuses on practical approaches to reducing risk through better documentation. Practice documenting patient care scenarios; learn tips on documenting in today's tough medical situations, review current laws; and leave with practical guidelines that will help you reduce your malpractice exposure. You owe it to yourself and your patients.

This unique seminar is packed with valuable guidelines and insights that will help you deal realistically, practically and effectively with the legal dilemmas you face in today's health care arena. Teaching methods include lecture, discussion, interactive exercises, handouts and case study analysis.

Workshop Objectives

At the conclusion of the workshop participants will be able to:

• Identify high risk situations in documentation

• Demonstrate defensible patient care documentation techniques

• Assess the pros and cons of EMR's

• Apply HIPAA Privacy Standards in practice

Program Schedule 

8:00           Registration, Deluxe Continental Breakfast

8:30-9:30    Identifying High Risk Situations in Practice
                 Why Patients Sue

9:30-10:30  Documentation Primer A to Z 
                 Subjective vs. Objective Charting
                 Using abbreviations, late entries, charting for others
                 Documentation Styles - narrative, charting by 
                 exception, SOAP, checklists, flowsheets, etc.
                 Documentation Issues eg. Physician orders, use of 
                 interpreters, adverse outcomes, etc.
                 
10:30-10:40 Break (10 minutes)

10:40-12:00 EMR's- The Pros and Cons
                  Data Entry, retrieval, customizing
                  Confidentiality safeguards
                  Factors to consider before you buy
                  Demo of various system features

                  HIPAA - Privacy Implications for Practice
                  

12:00-1:00   Lunch On Your Own

1:00-2:30     Documentation Tips, Talents & Techniques 
                  Practicum on documentation with an emphasis on
                  legal guidelines, protecting patient confidentiality, and 
                  enhancing provider communication. Participants will 
                  discuss scenarios of common patient care situations.

                   Release of Medical Records
                   (Authorization, in-person, per telephone, minors)
                  
                   Email (parameters of email usage in practice, email
                   standards, privacy policies) 

                   Faxing Parameters (policies &   
                   guidelines
                                      
                   Telephone Advice (leaving messages, prescription  
                   renewals)
                    
2:30-2:40 Break (10 minutes)

2:40-4 :15     Documentation Tips, Talents & Techniques 
                    
                    Informed consent (nurses role, problems, policy)
                   
                    Patient Teaching (use of videos, handouts, the 
                    Internet, Telemedicine, Netmeeting, demo of   
                    eHealth technology, etc.
                     
                    Follow-Up (criteria, responsibility of parties, how 
                    much is enough!)
                      
4:15-4:30      Summary & Evaluation

4:30             Adjourn

Featured Speaker:
Carol M. Stock, J.D., M.N., R.N., is principal of Carol M. Stock & Associates, a legal and health care consulting firm. An adjunct professor in Seattle Pacific University's Department of Graduate Nursing, Carol received her law degree from Seattle University and her master's degree in nursing from the University of Washington. She is a member of the Washington State Bar Association, the National Certification Corporation (NCC) Telephone Nursing Practice Content Team, and she helped draft the  AAACN's Telephone Nursing Practice Standards. Prior to practicing law, Carol was a family nurse practitioner in both rural and urban ambulatory care facilities. She lectures frequently on telephone nursing, risk management and legal issues in health care, and has developed an online Journal of E-Health Nursing

Who Should Attend

All health care professionals who document patient care will find this seminar especially valuable. Among those who should attend are nurses, clinical staff and other health care providers in all practice settings including hospitals, clinics, physician offices, urgent care, short stay surgery, home care, long-term care, and case management.

This ED 1 activity is approved for 8 contact hours by the Washington State Nurses Association, which is accredited as an approver of Continuing Education in Nursing by the American Nurses' Credentialing Center Commission on Accreditation.

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For In-House seminars call (206) 789-0909 for more information!