This program will cover the basics of documentation, including the “why” and “what”.  Principles of the documentation set out by ANA, expectations from CMS and Joint Commission regarding documentation will be covered.  Additionally, legal implications surrounding documentation will be addressed.

Included in the discussion will be case studies that present documentation and how the content, or lack thereof, resulted in either a decision for the healthcare provider or the plaintiff.

Objectives:-

• Recall ANA’s principles for nursing documentation.
• Describe the regulatory and professional requirements and expectations for documentation.
• Recall the basic requirements for documentation of clear, accurate, timely, and complete.
• Recall the importance of documentation in preventing and/or defending medical malpractice cases.

Who Should Attend?

• Clinical leads – charge nurses
• Nursing Educators
• Managers
• Compliance officers
• Patient Safety/Risk Managers
• Legal Counsel
• Nurses