Nursing Documentation: From Good to Great

Client safety, provider liability and reimbursement are directly correlated to the quality of the clinical documentation.   Nursing documentation requires critical thinking, the ability to analyze data and look at symptoms using a systems approach.  Whether it is to minimize legal risk, justify reimbursement, avoid neglect, or to support care decisions under survey scrutiny, the role of the nurse to chart effectively has never been more important and more difficult. Barriers to overcome continue to be limited time, charting accuracy, cohesiveness, and appropriate detail and use of partial or complete electronic record keeping .  Since good charting is your primary defense when faced with regulatory, legal, or reimbursement scrutiny, it's important to get your charting right! This course will take a hands on approach to review nursing documentation in compliance with regulatory standards, case studies and legal issues.  Participants will leave with enhance confidence in their ability to effectively document

1. Identify symptoms to assist nursing staff in resident assessment and problem identification
2. How to accurately document your findings to relay key incident details to other health care professionals
3. Gain tips on how to manage charting effectively under time limitations.
4. Describe the challenges of electronic health systems
5. Evaluate your charting systems through effective auditing.