Introduction: Legal Risks in Nursing Documentation (15:33)
Rosale Lobo describes her background and explains the outline for the class. If nurses do not document correctly, their license could be revoked. Electronic medical recording is designed more as a billing tool than a clinical one.
Care Plan: Facts vs. Fiction (13:32)
The North American Nursing Diagnosis Association (NANDA) regulates standards for the care plan process; document outcomes of interventions. Individualize your patient and document nuances. Attorneys look for assessments, interventions, and outcomes from nurses to build their case.
Standards of Care (09:22)
Standards of care differ by location, date, education, responsibilities, credibility, and facility policy and procedures. Those who are summoned as medical experts against the hospital should have a comparable degree as the one testifying. Legal nurse consultants assist in finding witnesses on LNC exchange.
Nursing Litigation and Documentation (28:59)
Lobo describes the first case of a nurse's testimony winning a lawsuit in a case of IV infiltration 40 years ago. Standards of care are determined by the Center for Medicaid and Medicare Services (CMS), Food and Drug Administration (FDA), the National Council for the State Board of Nursing and the Agency for Healthcare Research and Quality (AHRQ). Principles of Documentation 482.24c1 stipulates that the hospital ensures the nurse's keep a care plan that describes the patient's progress and response to medication and services.
Hospital Acquired Conditions & Infections (09:30)
Hospitals do not get reimbursed for some hospital acquired conditions. Intermediaries determine if nurses have deviated from set protocols. Learn where dropdown boxes are located and when timestamps occur; examine a patient from head to toe to avoid commission and omissions.
All Is Not What It Seems (11:47)
Never copy assessment data and Litigators are like investigative reporters. Report questionable conversations. Lobo provides a case study of a 90-year-old man who presented as an acute kidney trauma.
Theories of the Case (16:32)
Katie Jones provides a case study of a newborn who died three days after discharge who suffered from a congenital heart defect. All parameters were within normal limits except one respiratory rate. Vulnerable documentation occurs when there is a lack of coordination of care, timeline, or familiarity, making rapid decisions, poor working relationships, and not reading other nursing notes.
What Lawyers Don't Want You to Know (15:22)
Lawyers work collaboratively over a period of several months studying how best to approach a case; Law firms traditionally receive a third of the settlement or the verdict. Expert witnesses earn two to three times as a nurse's hourly rate and should have some professional clout. Lobo provides an example of a timeline chronology of a woman who died after a car accident.
Strategic Accountability (05:47)
Employ strategies and systems that help track the patient's progress. Identify the uniqueness of the patient while charting. Medication errors are one of the most common mistakes nurses make.
Do Not Be a Minimalist (07:42)
If something goes wrong, the documentation needs to explain exactly what occurred on a nurse's shift; lack of details could compromise patient safety. Be as aligned as possible with standards of practice. Identify the uniqueness of the patient while charting.
Physical Assessments (07:09)
Ask questions, compare sides, and approximate or measure abnormalities. Common errors include not writing unusual findings, medication side effects, and subtle assessment changes. Lobo describes a case study where a lack of follow up resulted in a patient dying from a cardiac arrest.
Roles of Legal Nurse Consultant (05:42)
Legal nurse consultants meet with potential clients, screen cases for merit, educate attorneys about healthcare nuances, create timeline chronologies, prepare deposition questions and witnesses, and locate expert witnesses.
Charting Tips and Techniques (12:16)
Keep your tone professional and do not reveal emotions. Requirements include reimbursement, policy/regulation, avoid penalties, and confirm nursing care; open blocks of time, failing to elaborate, mismatched orders, and conflicting timelines are vulnerable to litigation. Timestamps matter in litigation and are problematic can complicate the defense.
Elements of Litigation (06:51)
The four elements that must be demonstrated before a lawsuit can be filed are duty, breach of duty, damages/injury, and proximate causation. Negligent plaintiff allegations are failures to perform jobs properly. Hospitals can defend by proving that the plaintiff was contributory negligent. Steps in a lawsuit include obtaining research, hiring an expert witness, the discovery process, and trial or settlement.
How Do You Prepare for the Worst? (09:10)
Ask a lot of questions, be prepared, and composed; read as many entries as possible. Lawyers realize the software and the actual care of the patient do not align. When applying for another job, a nurse who has been sued must report the allegation.
Finale: Legal Risks in Nursing Documentation (03:29)
Nurses assess the patients, individualize their care, and employ strategies to improve charting. Manage the software. Watch your tone while documenting.
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