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Documentation: Legal and Administrative Considerations

Product code: M251B    Copyright © 2007
    

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."

Documentation: The Process

Product code: M251A    Copyright © 2007
    

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."

Legal Issues in Home Care: Risk Management and Patient Care

Product code: M181        

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.