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From the Frontlines: Why Documentation Is So Important

Date: 05/18/2021

9:00 AM - 10:30 AM

 

Target Audience:
CEO, COO, CNO, Compliance Officer, Joint Commission Coordinator, Quality Improvement personnel, Risk Manager, Legal Counsel.

Overview:
Accurate, concise documentation is the key to preventing claims of fraud and abuse, and is vital if the records are reviewed by the Centers for Medicare and Medicaid Services (CMS). Yet, many hospitals have seen an increase in documentation problems with the introduction of electronic health records. Our expert speaker will discuss the importance of documentation to avoid allegations of malpractice, substandard care, accreditation nightmares and denial of reimbursement, and will provide recommendations to improve documentation. This program will cover the basics of documentation including the principles set forth by the American Nurses Association (ANA), as well as expectations from the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission. Additionally, legal implications surrounding documentation will be addressed.Included in the discussion will be case studies that present documentation and how the content, or lack thereof, resulted in either a decision for the healthcare provider or the plaintiff.

Speaker:
Laura A. Dixon is the president of Healthcare Risk Education and Consulting. She previously served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided consultation and training to facilities, practitioners and staff in multiple states. Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided consultation to the physicians and staff for the western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, a Doctor of Jurisprudence degree from Drake University College of Law, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing. She is licensed to practice law in Colorado and California. 

This speaker has no real or perceived conflicts of interest that relate to this presentation.

Learning Objectives:

At the conclusion of this session, participants should be able to:

  • Recall the American Nurses Association’s principles for nursing documentation.
  • Describe the regulatory and professional requirements and expectations for documentation.
  • Recite the basic requirements for documentation are clear, accurate, timely and complete.
  • Demonstrate the importance of documentation in preventing and/or defending medical malpractice cases.