Product Details

 

This is a must-attend program for any nurse working in healthcare today. The program will discuss legal issues in documentation, offer advice on TJC and CMS Hospital CoP issues related to documentation, and review required fields in electronic medical records. This live training will also provide over 50 recommendations to help attendees improve their documentation skills.

Our expert will identify issues that need to be documented in order to maintain reimbursement by CMS and avoid allegations of fraud, abuse, and improper documentation by the recovery audit contractors. She will help hospitals use proper documentation to prevent unnecessary readmissions and transition to electronic medical records.

Concise documentation is key for preventing fraud.

Call us at 800.688.2421 or add this event to your cart above.

 

After this webinar, participants will be able to:

1. Identify ways to improve documentation to reduce the risk of liability.
2. Explain the importance of and what should be documented in the medical record.
3. Explain the specific requirements for documenting orders.
4. Describe CMS requirements for order sheets in approved protocols.
5. Describe CMS and TJC documentation requirements for verbal orders.

 

Agenda topics:

- RAC and documentation	- Discharge instructions	- Two-Midnight rule
- Observation status	- HIPAA amendment requirements	- Countersign
- Use of checklists	- Documenting for others	- Late entries
- Charting bloopers	- Document chain of command	- Code charting
- TJC's 2018 final pain standards	- OCR 1557 requirements	- 50 recommendations
- Admission assessments	- Admissibility of medical records	- Advance directives
- Observation patients	- Electronic medical records	- Unnecessary readmissions
- Incident reports	- Patient non-compliance	- MOON form
- Informed consent	- CMS & TJC verbal orders	And so much more!

 

Target Audience:

Anyone involved with documentation, including but not limited to: Nurses (all levels), Nurse Educators, Documentation Specialists, Health Information Management Directors and Staff, Chief Nursing Officers, Nursing Supervisors, Chief Operating Officers, Clinical Directors, Consumer Advocates, Risk Managers, and anyone involved in the documentation process.  

 

Your Speaker: Sue Dill Calloway, RN, MSN, JD

Sue is a nurse attorney, medico-legal consultant and long-time educator for nurses, physicians, and other healthcare providers. She is a frequent speaker and is well known across the country in the areas of healthcare law, risk management, and patient safety. She has authored over 100 books and hundreds of articles. For AHC Media, she authored Cracking the Code: Understanding the CMS Hospital CoP Standards on Anesthesia.

Ms. Calloway received her Bachelor of Arts, Bachelor of Science in Nursing, Master of Science in Nursing, and Doctor of Jurisprudence from Capital University in Columbus, Ohio. Additionally, she is certified in healthcare risk management by the American Society for Healthcare Risk Management and is the first in the country to be certified in CMS regulatory compliance.