Best Practices in Nursing Documentation: Writing Effective and Legal Proof Notes

Why Should You Attend:

Documentation is the backbone of Medical Necessity and support for services provided. Understanding what is required for documentation is essential. Inappropriate documentation can place you and your organization at risk for medical denials and legal recourse. Understanding what is needed within your documentation is your best defense against both an audit and legal investigations/ lawsuits. Legal issues can take years to be resolved and your documentation needs to survive the test of time.

This training session will cover what is needed within documentation to ensure that it will stand up to both a legal and medical review. It will demonstrate the necessity for accuracy and precision in documentation to decrease the risk of misinterpretation of information which could lead to negative repercussions by legal council or medical auditors.

Learning Objectives:

• Accuracy of entries – how to ensure this process
• Management of late or delayed entries
• Co-signatures – who is responsible for the content and what co-signing means
• Factual content versus “belief’s” or ‘theories”
• Notification to MD’s /Families
• Electronic Health Records – how they impact documentation

Areas Covered in the Webinar:

• Aspects of E.H.R and how it impacts documentation in positive and negative fashions
• Time sequence of documentation ; it’s importance and how to enter related information after the event
• Late entries ; why they happen and how to manage them
• Signatures what their significance is and why a signature page or record is required to support your electronic signature
• Co-signatures ; importance of correct use , how to modify an entry when co-signing documentation
• Fact’s versus opinions; the significance of accuracy of reporting without interpretation of events
• Need for response documentation ; what happened because of the treatment /action provided
• Communication with MD’s /Families and other groups ; why it is essential to include in the medical record

Who Will Benefit:

• Healthcare Administrators
• Nursing Directors
• Doctors
• Nurses
• Compliance officers
• Healthcare Policy Experts
• Healthcare Advocates
• Documentation
• Medical Records Clerks
• Rehab Staff

Laura S Hargraves
Independent Business Owner, Bridging Documentation

Laura S Hargraves, MS CCC- SLP RAC-CT, has been working in all aspects of the healthcare industry for the past 28 years. Ms. Hargraves has been providing compliance and oversight of documentation to meeting changing guidelines during this period. She has a background in education, which helps her maximize her ability to communicate these changes to the various professionals that she works with. She is an expert in documentation/compliance/audits and reviews. Ms. Hargraves is also a professional presenter on topics related to Medicare, MDS 3.0, and documentation.

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