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You are here > Home > Reading Lists > Nursing Management > Managing Documentation Risk: A Guide for Nurse Managers

Managing Documentation Risk: A Guide for Nurse Managers, 2nd Edition
Patricia DuClos Miller, RN, MS, CNA, BC

Softbound training manual: 204 pages + bonus CD-ROM  
Size: 8.5" x 11"
ISBN 1601460368
978-1601460363
HCPro
June 2007
(click button below for the very best currently available price for this important resource)

 


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, this resource 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?

 

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 provides strategies nurses can use to protect themselves and their organization while continuing to offer the best quality of care.

 

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:

  • Key aspects of nursing documentation

  • Reducing risk and culpability through defensive documentation

  • Contemporary nursing practice—Are you and your staff there?

  • Functions of the medical record

  • Nursing negligence—Understanding your risks and culpability

  • Depositions—Preparing for the worst

  • Improving staff documentation

  • Developing a foolproof documentation system

  • Auditing your documentation system

  • Electronic health records

  • Motivating your nurses to document completely and accurately

Intended audience for these resources - these are perfect resources 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

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.


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.

 

With more than 17 years of experience, HCPro, Inc. is a leading provider of integrated information, education, training, and consulting products and services in the vital areas of healthcare regulation and compliance. The company's mission is to meet the specialized informational, advisory, and educational needs of the healthcare industry. As an acknowledged industry authority in healthcare regulation and compliance, HCPro focuses on providing its expertise in the areas of accreditation, medical staff affairs, credentialing, privileging, medical record management, regulatory compliance, nursing, quality/patient safety, infection control, and workplace safety.

 

(information from the publisher)

 

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