WEBINAR: Documentation Update 2019; Ensuring Compliance
Course Curriculum
This program will focus on the importance of good documentation, which is key to avoiding allegations of malpractice and substandard care, accreditation nightmares, denial of reimbursement, and claims of fraud and abuse.
The program will cover legal issues in documentation and the Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS) hospital CoP issues related to documentation requirements. The speaker will provide over 50 recommendations to improve documentation and will detail the importance of documentation for pain assessment and TJC Record of Care medical records. CMS requirements of order sheets and the necessary protocols will also be covered.
Learning Objectives
At the conclusion of this session, participants will be able to:
1. Discuss recommendations to improve documentation to reduce the risk of liability.
2. Explain the importance of the assessment of pain and what should be documented.
3. Identify items that should be documented in a medical record as noted in the TJC Record of Care chapter.
4. Discuss the CMS requirement that all orders be in writing on the order sheet, even if hospitals use approved protocols.
5. Discuss the CMS and TJC standards that require specific documentation of verbal orders.
Speaker
Sue Dill Calloway, RN, JD
Sue Dill Calloway has been a nurse attorney and consultant for more than 30 years. Currently, she is president of Patient Safety and Healthcare Education & Consulting. She was previously the chief learning officer for the Emergency Medicine Patient Safety Foundation. Additionally, Calloway has authored over 100 books and numerous articles. The speaker has no real or perceived conflicts of interest that relate to this presentation.