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Sponsored by Lorman Education
Product ID: 401705EAU
Credit & Course Provided by:

Proper Documentation to Accurately Reflect Patient Progress and Enhance Patient Care

OnDemand Webinar (84 minutes)

Learn to identify resources and understand methods for documenting patient condition and progress.Health care providers have a duty to maintain an accurate and complete recording of all relevant events. Patient care and treatment which comports with acceptable medical and nursing standards of practice is of little value if not properly documented. Evaluate your personal documentation pattern and determine vulnerabilities that may exist. Immediately implement strategies that will decrease your exposure while enhancing the evidence of continuity and quality patient care.


Rachel Cartwright-Vanzant, Ph.D., MS, RN, LHRM, Medical Legal Concepts, LLC


Legal and Ethical Implications of Proper Documentation

Hospital Duties Owed to Patients

Liability; Personal and Managerial

Working With Computerized Medical Records



Failure to Meet Standards Established by Law

Medical Records Are Just as Important as Testimony in Trial

Know What to Chart and Know How to Chart

Charting Challenges: When Things Go Wrong

Fact Rule; Sample; OPQRST; Senses

Standards of Documentation

Implications of Evidence-Based Practice

Sources for Documentation Standards

Self-Serving Documentation

Falsification of Medical Records

Common Documentation Mistakes

Advanced Practice Nurses Scope of Practice

Defensive Strategies

Avoid Legally Risky Documentation

Effective Communication