Rachel Cartwright-Vanzant – Nursing Documentation

What You’ll Uncover in Rachel Cartwright-Vanzant Nursing Documentation

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Rachel Cartwright-Vanzant – Nursing Documentation

Course Description:

Should you have been required to testify in courtroom in protection of the care you supplied to a affected person, would your documentation be satisfactory to guard you from authorized legal responsibility? If the care you supplied got here beneath scrutiny months or years after it occurred, would your documentation allow you to precisely describe the usual of care delivered to the affected person? If you’re unsure, then you do not need to overlook this program!

Throughout this in-depth, interactive seminar, you should have the chance to evaluation actual courtroom circumstances and be taught from the precise testimonies supplied by nurses’ depositions. Rachel Cartwright-Vanzant, an unbiased authorized nurse advisor with over 28 years of medical, administration and consulting expertise, will offer you the data you might want to make sure that your documentation, whether or not hand-written or digital, depicts a stage of care that meets relevant requirements.

Discover ways to establish and keep away from dangerous documentation and combine practices that may preserve your license unblemished. What you be taught shall be instantly relevant to your follow and will preserve you out of the courtroom.

Targets:
Upon completion of this self-examine bundle, it is possible for you to to:

1. Describe the applying of the Nurse Follow Act/Legal guidelines to documenting care of sufferers.
2. Checklist ten methods to maintain your documentation notes and charts out of the courtroom.
3. Summarize the widespread documentation errors and keep away from and/or appropriate them.
4. Combine the proper practices into your documentation notes to maintain your license unblemished.
5. Checklist not less than 3 ways to safeguard digital documentation.
6. Evaluate and distinction the completely different types of nursing documentation and the way they’re used within the courtroom.
7. Make the most of precise medical malpractice circumstances to discover ways to enhance your documentation.
8. Display doc exactly and utterly when conditions are delicate and/or traumatic.

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Define:

1. Setting the Stage
   1. Many individuals learn medical information throughout a lawsuit
   2. Medical information are simply as necessary as testimony
2. Authorized and Moral Implications of Documentation
   1. Goal of the medical report within the courtroom
   2. “Get it right the first time”
   3. Requirements of documentation
   4. Methods to acknowledge deviations from the Commonplace of Care
3. Threat Administration & Documentation
   1. Incident experiences
4. Admissible Types of Nursing Documentation
   1. Widespread documentation errors
   2. Doctor orders
   3. Evaluation
   4. Plan of Care
   5. Drugs
   6. Interventions
   7. Tough, traumatic or delicate conditions
   8. Affected person training & responses
   9. Different codecs of documentation
5. Nursing Charting Methods
   1. Narrative
   2. SOAP
   3. PIE charting
   4. Focus charting
   5. Charting by exception
   6. Issues when utilizing circulate sheets
   7. Working with computerized medical information
6. Avoiding Legally Dangerous Documentation
   1. Credible proof
   2. Recording occasions objectively
   3. Sustaining factuality & thoroughness
   4. Avoiding ambiguity
   5. Avoiding bias
   6. Abbreviations to keep away from
   7. Late entries
   8. Private notes
   9. Correcting errors
7. Documentation & Bioethical Dilemmas
   1. Code of ethics
   2. Telling the reality
   3. Common rules of biomedical ethics
   4. ANA code for nurses
   5. Finish-of-life points
   6. Knowledgeable Consent & Therapeutic Privilege
8. Malpractice and Documentation
   1. Absence of knowledge
   2. Falsifying, tampering or masking up
   3. Penalties of tampering
   4. Forensic Doc Examiner’s function in report evaluation
9. Analyze a Actual Case Situation

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