Documentation: Legal Issues & Practice Pearls
M. Stock, JD, MN, RN
Do you spend too much time charting?
Have you ever sent or received a mis-directed fax or email and wondered what to do?
Are you unsure
about how much follow-up is enough?
Are you confused
over how to use email safely in practice?
Do you skip
documenting patient telephone advice?
Are you puzzled
about patient release of records?
Is your patient
teaching documentation vague and unclear?
Are you perplexed
over the legalities of EMR's (Electronic Medical Records)
Are you unclear
about HIPAA Privacy Standards in practice?
If you answered "Yes" to any of these, you should attend this seminar.
This interactive one-day seminar focuses on practical approaches to reducing risk through better documentation. Practice documenting patient care scenarios; learn tips on documenting in today's tough medical situations, review current laws; and leave with practical guidelines that will help you reduce your malpractice exposure. You owe it to yourself and your patients.
This unique seminar is packed with valuable guidelines and insights that will help you deal realistically, practically and effectively with the legal dilemmas you face in today's health care arena. Teaching methods include lecture, discussion, interactive exercises, handouts and case study analysis.
At the conclusion of the workshop participants will be able to:
Identify high risk situations
Demonstrate defensible patient care documentation techniques
Assess the pros and cons of EMR's
Apply HIPAA Privacy
Standards in practice
Deluxe Continental Breakfast
8:30-9:30 Identifying High Risk Situations in Practice
Why Patients Sue
9:30-10:30 Documentation Primer A to Z
Subjective vs. Objective Charting
Using abbreviations, late entries, charting for others
Documentation Styles - narrative, charting by
exception, SOAP, checklists, flowsheets, etc.
Documentation Issues eg. Physician orders, use of
interpreters, adverse outcomes, etc.
10:30-10:40 Break (10 minutes)
10:40-12:00 EMR's- The Pros and Cons
Data Entry, retrieval, customizing
Factors to consider before you buy
Demo of various system features
HIPAA - Privacy Implications for Practice
12:00-1:00 Lunch On Your Own
1:00-2:30 Documentation Tips, Talents & Techniques
Practicum on documentation with an emphasis on
legal guidelines, protecting patient confidentiality, and
enhancing provider communication. Participants will
discuss scenarios of common patient care situations.
Release of Medical Records
(Authorization, in-person, per telephone,
Email (parameters of email usage in practice, email
Faxing Parameters (policies &
Telephone Advice (leaving messages, prescription
2:30-2:40 Break (10 minutes)
2:40-4 :15 Documentation Tips, Talents & Techniques
(nurses role, problems, policy)
Patient Teaching (use of videos, handouts, the
Internet, Telemedicine, Netmeeting, demo of
eHealth technology, etc.
Follow-Up (criteria, responsibility of parties, how
much is enough!)
4:15-4:30 Summary & Evaluation
Carol M. Stock, J.D., M.N.,
R.N., is principal of Carol M. Stock & Associates, a legal and health
care consulting firm. An adjunct professor in Seattle Pacific University's
Department of Graduate Nursing, Carol received her law degree from Seattle
University and her master's degree in nursing from the University of
Washington. She is a member of the Washington State Bar Association, the National Certification Corporation (NCC) Telephone Nursing
Practice Content Team, and she helped draft the AAACN's Telephone Nursing Practice
Standards. Prior to practicing law, Carol was a family nurse
practitioner in both rural and urban ambulatory care facilities. She
lectures frequently on telephone nursing, risk management and legal issues
in health care, and has developed an online Journal of E-Health
Who Should Attend
All health care professionals who document patient care will find this seminar especially valuable. Among those who should attend are nurses, clinical staff and other health care providers in all practice settings including hospitals, clinics, physician offices, urgent care, short stay surgery, home care,
long-term care, and case management.
This ED 1 activity is approved for 8 contact hours by the Washington State Nurses Association, which is accredited as an approver of Continuing Education in Nursing by the American Nurses' Credentialing Center Commission on Accreditation.
here for registration form to print out.
For In-House seminars call (206) 789-0909 for more
Here for Home
Page Link to
Carol Stock Homepage