Protect against claims of poor-quality care and legal liability
As nurses are cited in malpractice cases more than ever before—and their documentation is called into question—do you know how to protect yourself and your facility?
All nurses at all levels need to understand what they are liable for when their nursing care is implicated in these cases. Managing Documentation Risk: A Guide for Nurse Managers, Second Edition provides nurse managers with strategies to protect themselves, their staff, and their organization while continuing to offer the best quality of care.
Completely updated with current regulations, Managing Documentation Risk: A Guide for Nurse Managers, Second Edition, provides the most current requirements from The Joint Commission and CMS, as well as the latest information on electronic health record documentation and nursing diagnoses.
Learn documentation dos and don’ts
This informative book for nurse managers illustrates situations in which poor documentation led to a nurse's care being cited and offers scenarios in which good documentation averted such troubles. With this valuable resource, nurse leaders will have the tools they need to assess their organization’s current risks and design a system for auditing staff documentation in the medical record.
Now includes bonus CD-ROM!
This resource now comes with an accompanying CD-ROM, including all the customizable strategic forms and audit tools included in the book ready for immediate use in your facility.
Take a look at the table of contents:
Chapter 1: Key aspects of nursing documentation
Chapter 2: Reducing risk and culpability through defensive documentation
Chapter 3: Contemporary nursing practice—Are you and your staff there?
Chapter 4: Functions of the medical record
Chapter 5: Nursing negligence—Understanding your risks and culpability
Chapter 6: Depositions—Preparing for the worst
Chapter 7: Improving staff documentation
Chapter 8: Developing a foolproof documentation system
Chapter 9: Auditing your documentation system
Chapter 10: Electronic health records
Chapter 11: Motivating your nurses to document completely and accurately
Intended audience
This book and CD-ROM is the perfect resource for nurse managers, chief nursing officers, directors of nursing, VPs of nursing, nurse educators, directors of education, and staff development specialists.
Learning objectives:
- Discuss how the nursing process is used in nursing documentation
- Describe how to use Nursing Outcomes Classification (NOC) in nursing documentation
- Identify risk management guidelines for nursing documentation
- Explain the consequences of incomplete nursing documentation
- Identify key components to include when documenting an adverse event
- Explain risk reduction recommendations for nurse managers
- List the components that make up contemporary nursing practice
- Discuss the importance of manager and staff familiarity with professional nursing standards
To view the full list of learning objectives, please click here.
Continuing Education
HCPro is accredited as a provider of continuing education by the American Nurses Credentialing Center Commission on Accreditation.
This educational activity for 3 nursing contact hours is provided by HCPro, Inc.
About the author
Patricia A. Duclos-Miller, MS, RN, CNA, BC, is a full-time associate professor in nursing at Capital Community College in Hartford, CT. During her 32 years in nursing, Duclos-Miller has served in a variety of roles, including staff nurse in the specialties of medical/surgical nursing, obstetrical nursing, and neonatal intensive care. She is a recognized speaker on contemporary nursing topics such as quality, team building, and documentation issues.
Faculty Disclosure Statement: HCPro Inc. has confirmed that none of the faculty/presenters or contributors have any relevant financial relationships to disclose related to the content of this educational activity.
Train your entire staff with the companion handbook—for less than $4 per person.
Improve your staff’s understanding of their documentation responsibilities and legal liabilities with the companion handbook Nursing Documentation: Reduce Your Risk of Liability, Second Edition. Written specifically for staff nurses, the handbook comes in a pack of 25 copies, and features easy-to-read tips on improving documentation. Through quick tips and illuminating case studies, it helps nurses understand the value of good documentation and the consequences of not documenting accurately and in a timely fashion. It will help motivate nurses to reach a level of excellence that will be reflected in the medical record, resulting in improved overall quality of care at the facility.
Follow this link to learn more about the handbook Nursing Documentation.
Want to save money by ordering the book and handbook together? Click here for more information about the toolkit.
If for any reason your purchase does not meet your needs, return it within 30 days and you will receive a prompt, polite, 100% refund—no questions asked.
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