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Author/Presenter:  

Length of Program: 120 minutes

30 Tips to improve documentation based on case law:

• Why document?

• Restraints (new requirements under HCFA)

• Safeguards to protect patients

• Spelling

• Abbreviation

• Charting by exception

• Code charting (JCAHO in hospital resuscitation standard)

• Avoid vague expressions

• Patient non-compliance

• AMA-EMTALA requirements

• Omitted or late entries

• Complete medication information et. al.

• Incident reports

• Patient education documentation

• Discharge instructions

• Documentation standards and how they are used in the courtroom

• JCAHO documentation standards for hospitals

• HCFA documentation standards for hospitals

CEOs, COOs, Compliance Officers, Risk Managers, Chief Nursing Executives, Nurse Managers, Consumer advocates, Information security officers, Legal counsel, Physicians, Health information management personnel, Privacy officer, Ethicists, Information technology personnel, Others with medical records responsibilities.

1. Name two tips to improve documentation.

2. List two things a nurse should document in a patient who wants to sign out against medical advice (AMA).

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