Description

Handouts

Outline

There are components of documentation.

• Guidelines
• Interpretation
• Mistakes
• Education
• Social Networking
• Indirect Care

Documentation for electronic nursing.

• American Recovery and Reinvestment Act
• Meaningful Use
• Health Insurance Portability and Accountability Act (HIPPA)
• Risky electronic documentation practices
• Dangers of email, social networking, and texting

Strategies for electronic medical records.

• Time Management
• Liability
• Software Knowledge
• Meaningful Use

Documentation and reimbursement.

• Medicare/Medicaid Changes
• Incentives and meaningful use criteria
• EMR Timelines
• Hospital Acquired Conditions

Things go wrong and there is documentation.

• Compliance
• Regulations
• CMC
• Incident Reports
• Adverse Events
• Risk Factors

There are ethical issues.

• Truth Tellers
• Standards
• Deviations
• Errors
• Omissions
• Communicating
• Corrections

Risky documentation can be avoided.

• Credible evidence
• Avoiding Ambiguity
• Recording events objectively
• Late Entries
• Correcting Errors

What if the worst happens?

• Duty /Breach of Duty
• Nurse Practice Act
• State Board of Nursing
• Depositions

There are examples and case studies of documentation.

Faculty

Brenda Elliff, RN, MPA, ONC, CCM, LNCC

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Elliff is a registered nurse and is a member of the ONC, CCM, and LNCC. Elliff Medical-Legal Services was established in 1996. She is a legal nurse consultant. She provides expert witness preparation and performs record reviews.

Medical Malpractice, Worker’s Compensation, Personal Injury, and a variety of legal cases are her work. She taught a Legal Nurse Consultation review course and worked as a Health Care Coordination for a large law firm. She expanded her scope throughout the Pacific NW after working with attorneys in California.

She has been a clinical nurse for 40 years. As a staff nurse, as a nurse manager at major teaching facilities, as a nurse case manager, and as an adjunct nursing professor, she has worked.

When she isn’t nursing, she likes to participate in a local performing group. The group performed in the LA Christmas Parade. th Washington DC has a cherry blossom parade.

Past nurses who have attended the programs have appreciated the fun and dynamic way in which she delivers information. She has been a sought-after speaker at national, state and local levels, on a variety of topics that draw from her areas of expertise.

Speaker disclosures.

Elliff has a private practice. She is paid by PESI, Inc.

There are no relevant non-financial relationships disclosed by Elliff.