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Documentation: Legal and Administrative Considerations

Product code: M251B        Reviewed for accuracy: 2011

Overview:

Documentation, the recording of a patient's condition, treatment and response to treatment, is one of the most basic nursing skills. But its importance to both the patient and the nurse providing care cannot be overstated. This is because the medical record fulfills three important functions:

• First, it provides information about the patient's current condition, treatment response, and progress.
• Second, it serves as a legal record of the care provided.
• Third, it provides information used for reimbursement by third party payers.
  
  

This two-part series on documentation provides nurses and others with an understanding of the importance of accurate and objective charting in order to assist the patient's continuing care and of the legal and administrative considerations related to healthcare documentation. It addresses issues such as meeting documentation standards required by the Joint Commission's National Patient Safety Goals, the use of charts for performance improvement activities and concerns about privacy considerations and new technology such as camera phones and online "blogs".

Objectives:

After completing this course, the viewer should be able to:

• Explain why accurate documentation is so important from a legal standpoint.
• List the most common types of documenting mistakes and sources on inaccuracy.
• Explain the importance of maintaining patient confidentiality.
• Describe strategies to preserve patient confidentiality at all times.
• Explain how new record keeping technologies affect patient confidentiality.
• Explain how to address issues related to noncompliance, unusual occurrence reports and administrative considerations.

Documentation: The Process

Product code: M251A        Reviewed for accuracy: 2011

Overview:

Documentation, the recording of a patient's condition, treatment and response to treatment, is one of the most basic nursing skills. But its importance to both the patient and the nurse providing care cannot be overstated. This is because the medical record fulfills three important functions:

• First, it provides information about the patient's current condition, treatment response and progress.
• Second, it serves as a legal record of the care provided.
• Third, it provides information used for reimbursement by third party payers.
  
  

This two-part series on documentation provides nurses and others with an understanding of the importance of accurate and objective charting in order to assist the patient's continuing care and of the legal and administrative considerations related to healthcare documentation. It addresses issues such as meeting documentation standards required by the Joint Commission's National Patient Safety Goals, the use of charts for performance improvement activities and concerns about privacy considerations and new technology such as camera phones and online "blogs".

Objectives:

After completing this course, the viewer should be able to:

• Explain the purpose and importance of maintaining accurate and objective documentation
• Describe how to perform documentation in order to maintain objectivity, accuracy and comprehensiveness
• List the various types of documentation that are contained within a patients healthcare record

Legal Issues in Home Care: Risk Management and Patient Care

Product code: M181        Reviewed for accuracy: 2011

Overview:

Managing the many risks associated with providing patient care in the home is an important challenge. This program explains the risks and demonstrates procedures designed to reduce risks. Topics also include patient selection, patient and caregiver education, staff competence, incident reporting, patient confidentiality and informed consent.