Nursing Documentation Pitfalls
Legal Risks in the Critical Care Setting
- Speaker:
- Pam Collins, MSN, CMSRN, RN-BC
- Duration:
- 2 Hours 01 Minutes
- Format:
- Audio and Video
- Copyright:
-
Nov 09, 2022
- Product Code:
- POS078483
- Media Type:
- Digital Seminar
Description
"If you didn’t chart it, you didn’t do it" may sound over-rated, but in a court of law, this can make or break the case! This session will reveal strategies to help make your documentation court ready. You will learn the most common documentation errors that can change the course of a lawsuit, how to accurately reflect the care that you provided, and of course what should not be documented. Regardless of your critical care role, this session will help to ensure that your documentation holds up in court!
Credit
Handouts/Brochure
| File type | File name | Number of pages | |
|---|---|---|---|
| Manual - Nursing Documentation Pitfalls (1.4 MB) | 30 Pages | Available after Purchase | |
| Transcript - Nursing Documentation Pitfalls (120 KB) | 21 Pages | Available after Purchase |
Speaker
Pam Collins, MSN, CMSRN, RN-BC Related seminars and products
Pam Collins, MSN, CMSRN, RN-BC, has 40 years of varied nursing experiences that includes administration, nursing faculty, staff nurse, extensive experience as a nursing professional development practitioner with a focus in leadership development, and work as an education and legal consultant. Pam has served as an expert witness for plaintiff and defense medical malpractice cases, specific to nursing. She is dually certified in medical-surgical nursing from the American Nurses Credentialing Center and the Academy of Medical-Surgical Nurses, is also certified in nursing professional development, and has a proven track record of helping nurses achieve certification in medical-surgical nursing and nursing professional development.
Pam’s accomplishments include being a published author in nursing journals and textbooks, and just recently authored a medical-surgical certification review book. Pam has served on the advisory panel for the American Nurses Credentialing Center, has been the recipient of various awards for her contribution to education and nursing professional development, and was a flight nurse in the United States Air Force Reserve. Pam presents nationally on clinical and legal topics and is known for her ability to engage the audience.
Speaker Disclosures:
Financial: Pamela Collins maintains a private practice and has an employment relationship with Atrium Health System. She receives a speaking honorarium and recording royalties from PESI, Inc. She has no relevant financial relationships with ineligible organizations.
Non-financial: Pamela Collins is a member of the Academy of Medical-Surgical Nurses, the American Nurses Association, and the § Association for Nursing Professional Development.
Additional Info
Access for Self-Study (Non-Interactive)Access never expires for this product.
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Objectives
- Analyze common sources of lawsuits for healthcare professionals.
- Evaluate the most significant pitfalls in nursing documentation.
- Implement strategies to perform legally defensible documentation.
- Practice how to document high-risk patient situations.
Outline
- Current Lawsuit Trends
- Specialties at higher risk for litigation
- Top sources of nursing malpractice/negligence
- Common Pitfalls of Documentation
- Vagueness
- Omissions
- Words to use/avoid
- Late entries
- Inconsistency
- How to document high-risk situations and conversations
- Patient refusal
- MD/Provider notification
- Discharge education
- Electronic Documentation: Dos and Don’ts
- Proper use of flowsheets
- When to add narrative notes
- Proper timing of entries
Target Audience
- Nurses
- Nurse Practitioners
- Clinical Nurse Specialists
- Physician Assistants
Reviews
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