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Rosale Lobo - Nursing Documentation: Proven Strategies to Keep Your Patients and Your License Safe

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Join expert and legal nurse consultant, Rosale Lobo, PhD(c), MSN, RN, CNS, LNCC, to learn how to develop a systematic approach to documentation that will k...
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Information

Faculty:
Rosale Lobo
Duration:
Full Day
Format:
Audio and Video
Copyright:
May 11, 2016

Description

Join expert and legal nurse consultant, Rosale Lobo, PhD(c), MSN, RN, CNS, LNCC, to learn how to develop a systematic approach to documentation that will keep you, your patients and your license safe. You will learn how to identify and avoid risky documentation as well as how to correctly utilize electronic documentation and the correct technique for meaningful use. Rosale will show you step by step, how to overcome your most complex documentation questions and challenges.

This dynamic one-day program will include tools to safeguard your documentation including:

  • Time saving tips for electronic documentation and EMR use
  • Documenting compliance, incident reports, and adverse events
  • Sample strategy worksheets for ease of data collection
  • Federal government requests for charting based on meaningful use criteria
  • Dangers with social media, email, and texting
  • Examples and case studies of correct and incorrect documentation

 

Handouts

Outline

The Components of Documentation

  • Guidelines
  • Interpretation
  • Mistakes
  • Education
  • Social Networking
  • Indirect Care

Electronic Nursing Documentation

  • American Recovery and Reinvestment Act
  • Meaningful Use
  • Health Insurance Portability and Accountability Act (HIPPA)
  • Risky electronic documentation practices
  • Dangers of email, social networking, and texting

Electronic Medical Records (EMR) Strategies

  • Time Management
  • Liability
  • Software Knowledge
  • Meaningful Use

Reimbursement and Documentation

  • Medicare/Medicaid Changes
  • Incentives and meaningful use criteria
  • EMR Timelines
  • Hospital Acquired Conditions

Documentation When Things Go Wrong

  • Compliance
  • Regulations
  • CMC
  • Incident Reports
  • Adverse Events
  • Risk Factors

Ethical Issues

  • Truth Tellers
  • Standards
  • Deviations
  • Errors
  • Omissions
  • Communicating
  • Corrections

Avoiding Risky Documentation

  • Credible evidence
  • Avoiding Ambiguity
  • Recording events objectively
  • Late Entries
  • Correcting Errors

What if the Worst Happens?

  • Duty /Breach of Duty
  • Nurse Practice Act
  • State Board of Nursing
  • Depositions

Examples and Case Studies of Documentation

 

Faculty

Nursing Documentation: Proven Strategies to Keep Your Patients and Your License Safe

Rosale Lobo, PhD, MSN, RN, CNS, LNCC Related seminars and products: 8

Adjunct Professor

Southern Connecticut State University


Rosale Lobo, PHD, MSN, RN, CNS, LNCC, has 30 years of combined experience as a direct care nurse, faculty, administrator, and legal nurse consultant. Rosale is a staff nurse at a large teaching hospital in Connecticut and serves as clinical faculty at Southern Connecticut State University. She began working with attorneys in North Carolina and expanded her independent legal nurse consulting practice to New York, Georgia, Colorado, and Connecticut. Plaintiff medical malpractice attorneys have utilized her expertise as both an expert witness and a "behind-the-scenes" consultant.

Rosale is a BSN graduate from Long Island University, earned her master's degree from Hunter College with magna cum laude distinction and her PhD from Walden University, focusing her dissertation research on Nursing Documentation. Rosale is the author of Guilty or Innocent: Protecting Your License Through Proper Nursing Documentation (PHC Publishing Group, 2012). She is a member of the American Nurses Association, American Association of Legal Nurse Consultants, past educational board member for the Connecticut Association of Legal Nurse Consultants, and the American Society of Public Administration.

Speaker Disclosures: 

Financial:  Rosale Lobo is an Adjunct Clinical Faculty for Southern Connecticut State University and Gateway Community College. She receives royalties as an author for PESI Publishing & Media. Ms. Lobo receives a speaking honorarium from PESI, Inc.

Non-financial:  Rosale Lobo has no relevant non-financial relationship to disclose.