Defensive Documentation for Long-Term Care
Improper documentation in the medical record has landed plenty of facilities in hot water when used as evidence in a lawsuit. Defensive Documentation for Long-Term Care: Strategies for Creating a More Lawsuit-Proof Resident Record can show you how to protect your facility by making sure your medical records documentation is right on target.
Nursing homes, afraid of being sued for crippling amounts of money, want to do everything they can to suit-proof their business. The medical record is often where they're most vulnerable. In a lawsuit, poor documentation can be used as evidence against a facility, even if care was actually performed properly. Proper documentation, on the other hand, can be used in a facility's defense and contribute to lower insurance rates.
A thorough, yet concise read, Defensive Documentation for Long-Term Care explains how to fill out the various pieces of the medical record in a manner that makes it least vulnerable should it be used as evidence in a lawsuit. It gives charting examples of "good" and "bad" documentation and explains how to avoid common documentation pitfalls. It also outlines several different techniques nurses and other caretakers can use to document resident care in a way that could be defended in court.
Defensive Documentation for Long-Term Care . . .
- Explains what you should include in a resident's chart, and what you should avoid
- Discusses how to handle common documentation challenges, such as the initial assessment, adverse events, and refusal of medication/treatment/nutrition/fluids
- Outlines common mistakes people make when documenting for long-term care
- Pinpoints the entries that are most often omitted from medical records
- Describes different successful documentation formats
- Directors of nursing
- Staff trainers
- MDS coordinators
- Risk managers in nursing homes and assisted living facilities
Don't let your facility be vulnerable when it comes to documentation for the medical record. Order Defensive Documentation for Long-Term Care today!
Product Types :