The Components of Documentation
- Guidelines
- Interpretation
- Mistakes
- Education
- Social Networking
- Indirect Care
Electronic Nursing Documentation
- American Recovery and Reinvestment Act
- Meaningful Use
- Health Insurance Portability and Accountability Act (HIPPA)
- Risky electronic documentation practices
- Dangers of email, social networking, and texting
Electronic Medical Records (EMR) Strategies
- Time Management
- Liability
- Software Knowledge
- Meaningful Use
Reimbursement and Documentation
- Medicare/Medicaid Changes
- Incentives and meaningful use criteria
- EMR Timelines
- Hospital Acquired Conditions
Documentation When Things Go Wrong
- Compliance
- Regulations
- CMC
- Incident Reports
- Adverse Events
- Risk Factors
Ethical Issues
- Truth Tellers
- Standards
- Deviations
- Errors
- Omissions
- Communicating
- Corrections
Avoiding Risky Documentation
- Credible evidence
- Avoiding Ambiguity
- Recording events objectively
- Late Entries
- Correcting Errors
What if the Worst Happens?
- Duty /Breach of Duty
- Nurse Practice Act
- State Board of Nursing
- Depositions
Examples and Case Studies of Documentation