Documentation-Legal

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Documentation: Electronic Medical Records Federal Regulations

Product code: M251BR        

Series Overview:

Though not a therapy or course of treatment, documentation is a critical component of providing nursing care. Whether electronically or in print, the recording of a patient's condition, treatment and response to treatment, provides the crucial information needed by each members of the patient’s healthcare team that allows them to provide their specialized care. In addition to assisting with patient care, it can protect the nurse from legal action by demonstrating that needed care was provided.

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.

The programs in the series provide a total of 1 hour of continuing nursing education.

Overview:

Documentation of patient care using electronic medical records (EMR) has become method preferred by many healthcare organizations and is both encouraged and mandated by the federal government. This program provides the nurse with an understanding of EMRs advantages that can be of benefit, and potential disadvantages that must be avoided and addressed. In addition it will provide an overview of the impact of federal mandates such as the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) act on EMR.

Objectives:

After completing this course, the viewer should be able to:
  • Describe at least four advantages provided by EMR
  • Describe the Joint Commission’s recommendations for the use of scribes
  • Describe strategies to prevent breaches of patient confidentiality.
  • Describe some changes to HIPAA that occurred with passage of the HITECH Act

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Documentation: Essentials of Nursing Documentation

Product code: M251AR        

Series Overview:

Though not a therapy or course of treatment, documentation is a critical component of providing nursing care. Whether electronically or in print, the recording of a patient's condition, treatment and response to treatment, provides the crucial information needed by each members of the patient’s healthcare team that allows them to provide their specialized care. In addition to assisting with patient care, it can protect the nurse from legal action by demonstrating that needed care was provided.

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.

The programs in the series provide a total of 1 hour of continuing nursing education.

Overview:

This program describes commonly used approaches to documentation, a review of the basic data to record in patient records, and practice guidelines to follow that protect patient privacy, comply with federal regulations and protect the nurse against potential legal actions.

Objectives:

After completing this course, the viewer should be able to:
  • Describe the functions of medical records
  • Describe five commonly used approaches to documentation
  • List the most common types of documenting mistakes and sources of inaccuracy
  • Explain the importance of maintaining patient confidentiality
  • Describe strategies to preserve patient confidentiality at all times
  • Explain how to address issues related to noncompliance, unusual occurrence reports and administrative considerations

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