“Documentation in the New Age: A Nurses’ Best Defense”
Accurate documentation of patient symptoms, observations, changes in condition, and treatments given is critically important as nurses and healthcare professional practitioners become more concerned about protecting themselves from disciplinary action and legal liability. Documentation in nursing is also an important medico-legal requirement of nursing practice, and an integral part of evidencing the provision of quality and safe care to our patients. Documentation of patient centered care integrates the concepts that the interprofessional team is able to work together, ensure that each patient’s individual needs are clearly communicated to one other, and develop a patient specific plan of care that can be carried out by all practitioners. The law expects nurses to act in the same way that a reasonably prudent nurse, with the same level of training and experience, would act in a similar situation. The medical record, therefore, will be scrutinized line by line and in part to ascertain whether this legal standard is met. As such, an accurate, factual, concise, and individualized medical record is a nurse’s best defense. Join us as we analyze and discuss competencies in nursing documentation.
This program is intended for nurses who want to deconstruct and review the structure of progress note and EMR entries and analyze whether the note properly focuses on patient assessment, nursing actions, patient responses, and nursing recommendations. Participants of this program will be afforded the opportunity to analyze case studies, write their own nurses note, and engage in a group evaluation of the nursing record. Additionally, this program will offer nurses the opportunity, through role play and case scenarios, to demonstrate competency and best practices in medical record documentation in nursing specialty practice areas.
Upon completion of this program, the participant will be able to:
- Provide a definition of “documentation
- Discuss the purposes of documentation
- Identify three recording systems of nursing care
- Describe the benefits and pitfalls of various systems of nursing documentation
- Identify three regulatory bodies providing directives for documentation
- Identify three appropriate documentation methods
- Identify five legal issues that arise with inappropriate documentation
- Discuss disciplinary actions that employers use to address inappropriate documentation practices
- Discuss emerging documentation concerns regarding electronic medical record systems, faxing, and texting
- Compare and contrast competencies in nursing documentation examples
- Examine a wide variety of clinical situations, variables related to patient diversity, patient prioritization issues, legal and ethical considerations
- Discuss evidence based practices that illustrate provision of nursing care in accordance with scope and standards of practice
- Distinguish between appropriate standards of ethical and legal practice interventions
- Recognize documentation practices that create legal and professional risks
- Demonstrate competency and best practices in medical record documentation in nursing specialty practice areas
- Develop a patient specific care plan that illustrates the provision of nursing care in accordance with best practices and standards of practice
The New York State Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This program has been awarded 18.5 contact hours through the New York State Nurses Association Accredited Provider Unit.
The New York State Nurses Association is accredited by the International Association for Continuing Education and Training (IACET) and is authorized to issue the IACET CEU. The New York State Nurses Association is authorized by IACET to offer 1.8 CEUs for this program.
NYSNA wishes to disclose that no commercial support or sponsorship was received.
NYSNA Program Planners and Presenters declare that they have no conflict of interest in this program.
Declaration of vested interests: None.