Protect against claims of poor-quality care and legal liability
As a nurse, documentation may be the least favorite part of your job—but it’s also one of the most important aspects. Incomplete or improper documentation poses a huge financial and compliance threat, including citations from state, federal, and Joint Commission surveyors.
Completely updated with current regulations, Managing Documentation Risk: Tools 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 records documentation and nursing diagnoses.
As nurses are now 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?
Learn documentation dos and don’ts
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: Tools for Nurse Managers, Second Edition provides strategies nurses can use to protect themselves and their organization while continuing to offer the best quality of care.
In this second edition of our best-selling toolkit, you’ll find:
- Managing Documentation Risk: A Guide for Nurse Managers, Second Edition
Many nurse managers don’t realize that they can be held accountable for their nurses’ documentation. Reduce risk by educating staff on the consequences of poor documentation.
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 current risks and design a system for auditing staff documentation in the medical record. By effectively training staff members to properly and efficiently document, healthcare leaders will protect themselves, their staff, and their organization from potentially damaging allegations of negligent care.
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
- Nursing Documentation: Reduce Your Risk of Liability, Second Edition (pack of 25 copies)
This handbook, written specifically for staff nurses, features tips on improving documentation. It will help 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 a level of excellence that will be reflected in the medical record, resulting in improved overall quality of care at their facility.
- More value for your money
Managing Documentation Risk: A Guide for Nurse Managers, Second Edition 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.
Intended audience
Managing Documentation Risk: Tools for Nurse Managers, Second Edition 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.
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