Synopsis
Protect against claims of poor-quality care and legal liability
Learning objectives:
This resource equips nurse managers with strategies to protect themselves, their staff, and their organization while continuing to offer the best quality of care. It provides requirements from The Joint Commission and CMS, as well as information on electronic health record documentation and nursing diagnoses.
Learn documentation dos and don’tsThis informative book for nurse managers illustrates situations in which poor documentation led to a nurse’s care being cited and offers scenarios in which good documentation averted such troubles. With this valuable resource, nurse leaders will have the tools they need to assess their organization’s current risks and design a system for auditing staff documentation in the medical record.
Includes a bonus CD-ROM!This resource includes an accompanying CD-ROM with customizable strategic forms and audit tools.
Take a look at the table of contents:Chapter 1: Key aspects of nursing documentation
Chapter 2: Reducing risk and culpability through defensive documentation
Chapter 3: Contemporary nursing practice—Are you and your staff there?
Chapter 4: Functions of the medical record
Chapter 5: Nursing negligence—Understanding your risks and culpability
Chapter 6: Depositions—Preparing for the worst
Chapter 7: Improving staff documentation
Chapter 8: Developing a foolproof documentation system
Chapter 9: Auditing your documentation system
Chapter 10: Electronic health records
Chapter 11: Motivating your nurses to document completely and accurately
Learning objectives:
- Discuss how the nursing process is used in nursing documentation
- Describe how to use Nursing Outcomes Classification (NOC) in nursing documentation
- Identify risk management guidelines for nursing documentation
- Explain the consequences of incomplete nursing documentation
- Identify key components to include when documenting an adverse event
- Explain risk reduction recommendations for nurse managers
- List the components that make up contemporary nursing practice
- Discuss the importance of manager and staff familiarity with professional nursing standards
Improve your staff’s understanding of their documentation responsibilities and legal liabilities with the companion handbookNursing Documentation: Reduce Your Risk of Liability, Second Edition. Written specifically for staff nurses, the handbook comes in a pack of 25 copies, and features easy-to-read tips on improving documentation. Through quick tips and illuminating case studies, it helps nurses understand the value of good documentation and the consequences of not documenting accurately and in a timely fashion. It will help motivate nurses to reach a level of excellence that will be reflected in the medical record, resulting in improved overall quality of care at the facility.
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About the Author
Patricia A. Duclos-Miller, MS, RN, CNA, BC, is a full-time associate professor in nursing at Capital Community College in Hartford, CT. During her 32 years in nursing, Duclos-Miller has served in a variety of roles, including staff nurse in the specialties of medical/surgical nursing, obstetrical nursing, and neonatal intensive care. She is a recognized speaker on contemporary nursing topics such as quality, team building, and documentation issues.
"About this title" may belong to another edition of this title.
