Legal Documentation Aug 2008

Nursing Documentation Your License may depend on it! Shelia Duncan RN, CCRN Nov. 2007 February 2008 August 2008 November 2008

CE ANNOUNCEMENTS ,[object Object],[object Object],[object Object],[object Object],[object Object]

Taking a Poll ,[object Object],[object Object],[object Object]

[object Object],[object Object]

Legal Case Studies ,[object Object]

What does the “jurors” see and hear?? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

“ Duty of Care” ,[object Object],[object Object],[object Object]

Breach of Duty ,[object Object],[object Object],[object Object],[object Object],[object Object]

Nursing Negligence / Malpractice ,[object Object],[object Object]

Proximate Cause ,[object Object],[object Object]

Foreseeability ,[object Object],[object Object],[object Object],[object Object]

Illusion of Negligence ,[object Object]

Damages ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Objectives ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Objectives ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Who Cares? ,[object Object],[object Object],[object Object],[object Object]

"if it's not documented it was not done" ,[object Object]

Standards of Care ,[object Object],[object Object]

North Carolina ,[object Object],[object Object],[object Object]

http://www.ncbon.com/Practice.asp

Prudent Nurse ,[object Object],[object Object],[object Object],[object Object]

Liability: Chain of Command ,[object Object]

What Is the Chain of Command? ,[object Object],[object Object]

Chain of Command? ,[object Object],[object Object],[object Object],[object Object]

Why Is the Chain Important? ,[object Object]

Initiation of the Chain… ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Examples Clinical Situations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Documenting This Process “Chain of Command” ,[object Object],[object Object],[object Object]

Policy & Procedure ,[object Object],[object Object],[object Object]

Negligence? ,[object Object],[object Object],http://ahweb/intranet/Policies/Nursing%20Policies/Nursing%20Standards.pdf http:// www.youtube.com/watch?v =TaV1gL3xzbE

Expert Witnesses ,[object Object]

Responsibility ,[object Object],[object Object],[object Object],[object Object]

Source of Liability ,[object Object],[object Object]

Documentation Standard Policy ,[object Object],[object Object],[object Object],[object Object]

Case in Point ,[object Object]

Master of Charting ,[object Object]

The Basics ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Legibility ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Date & Time ,[object Object],[object Object],[object Object],[object Object],[object Object]

Client’s History ,[object Object],[object Object],[object Object],[object Object]

Subject & Objective ,[object Object],[object Object],[object Object],[object Object]

Changes in Health Status ,[object Object],[object Object],[object Object]

Client Outcomes ,[object Object],[object Object],Case in point: pain

Actual Response ,[object Object],[object Object],[object Object]

Your Signature ,[object Object],[object Object],[object Object],[object Object],Shelia Duncan RN, CCRN - SD ICU Educator

A Little More than The Basics ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Client Education ,[object Object],[object Object]

Referrals & Consents ,[object Object],[object Object],[object Object],[object Object]

SBAR ,[object Object],[object Object],[object Object],[object Object],Communication

Phone Calls ,[object Object],[object Object],[object Object],[object Object],[object Object],Communication

Client Call Office Scenario ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Communication

Client Call Hospital Scenario ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Communication

“Read Back” ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Communication

Faxes & Computerized Records ,[object Object],[object Object]

Safeguards for Faxing ,[object Object],[object Object],[object Object]

Computerized Documentation ,[object Object],[object Object],[object Object]

Guide to Computer Documentation ,[object Object],[object Object],[object Object]

Guide to Computer Documentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Guide to Computer Documentation ,[object Object],[object Object],[object Object],[object Object]

Guide to Computer Documentation ,[object Object]

Make Documentation Easier ,[object Object],[object Object]

The Do’s ,[object Object],[object Object],[object Object],[object Object],[object Object]

Clear / Concise / Accurate ,[object Object]

Do’s ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Do’s ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Do’s ,[object Object],[object Object],[object Object],[object Object],[object Object]

Do’s ,[object Object],[object Object],[object Object],[object Object]

Do’s ,[object Object],[object Object]

The Don'ts ,[object Object],[object Object],[object Object]

Red Flags ,[object Object],[object Object],[object Object],[object Object],[object Object]

Don’t ,[object Object],[object Object],[object Object],[object Object]

Don’t ,[object Object],[object Object],[object Object]

Fraud ,[object Object],[object Object]

When you make a Mistake ,[object Object],[object Object],[object Object],[object Object],[object Object],Don't

RN * LPN * CNA Differences ,[object Object],[object Object],[object Object]

WHEN THE LICENSED NURSE DELEGATES PATIENT CARE ACTIVITIES TO UAPs

WHEN THE PHYSICIAN DELEGATES PATIENT CARE ACTIVITIES TO UAPs

RN ,[object Object],[object Object],[object Object]

Standardized Nursing Care Plan ,[object Object],[object Object]

Clinical Care Path ,[object Object],[object Object],[object Object],[object Object],[object Object]

Kardex ,[object Object],[object Object]

Nurses Notes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Nurses Notes Narrative ,[object Object],[object Object],[object Object],[object Object]

Universal Guideline for Charting “Nursing Process” ,[object Object],[object Object],[object Object],[object Object],[object Object]

Documentation Audits ,[object Object],[object Object]

How to prove Malpractice ,[object Object],[object Object],[object Object],Webster States:

Common Charting Mistakes ,[object Object],[object Object],[object Object],[object Object]

Failing to record pertinent health or drug information ,[object Object],[object Object],[object Object],[object Object]

Failing to record nursing actions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Failing to record that medications have been given ,[object Object],[object Object],[object Object],[object Object],[object Object]

Recording on the wrong chart ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Failing to document a discontinued medication ,[object Object],[object Object],[object Object],[object Object],[object Object]

Failing to record drug reactions or changes in the patient’s condition ,[object Object],[object Object],[object Object],[object Object]

Transcribing orders improperly or transcribing improper orders ,[object Object],[object Object],[object Object],[object Object]

Writing illegible or incomplete records ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Documentation – The wrong way! ,[object Object]

Ketchum vs. Overlake Hospital Medical Center 1991 ,[object Object]

Expert Nurse Witness Prosecution ,[object Object],[object Object],[object Object]

Expert Nurse Witness Defense ,[object Object],[object Object],[object Object]

Pivotal Issue ,[object Object]

Jarvis vs. St. Charles Medical Center 1986 ,[object Object]

Pivotal Issues ,[object Object],[object Object]

Inconsistent Nurses Notes ,[object Object],[object Object],[object Object]

Ard vs. East Jefferson General Hospital ,[object Object]

Nurse Availability Call Bell ,[object Object]

Wrongful Death ,[object Object]

Nurse Expert ,[object Object],[object Object],[object Object]

Medical Expert ,[object Object]

Lessons Learned ,[object Object],[object Object]

Defensive Documentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Documentation – The right way!

Professional Liability Coverage ,[object Object],http://www.nso.com/customer/faq_cov.php

Professional Liability Coverage ,[object Object],[object Object]

Case Study “Mock Trial” ,[object Object]

Examples ,[object Object],[object Object],[object Object],[object Object]

References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Legal Documentation Aug 2008

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Legal Documentation Aug 2008