Legal Aspects of Documentation

 

As a healthcare professional, you have often heard the adage that says, “If you didn’t document something, you didn’t do it.” It is no longer true that you can be exempt from malpractice or negligence claims because you were following orders. As a professional in the healthcare industry, you are expected to be familiar with many aspects of care. If you are a nurse, you are responsible for assessing, planning, implementing, and evaluating nursing care. If you are a social worker, you are responsible for assessing, planning, implementing, and evaluating psychosocial care. What you document can and does reflect that care planning and resulting outcomes if the documentation is factual, complete, timely, and detailed. In this course, you will learn about concepts and rules regarding documentation in the medical record as it relates to negligence, malpractice, and intentional torts.

$40.00

Hours: 1.00
REL-SRC-0-LAD

Certificates

Certificates provided by accrediting body (14 Match)

California Board of Registered Nursing

1.0 HOURS


Provider approved by the California Board of Registered Nursing, CEP# 13791

Nurses will receive 1.00 contact hours for participating in this course.

District of Columbia Board of Nursing

1.0 HOURS


DC-RN -- District of Columbia Board of Nursing Approved Continuing Education program (CE Provider #50-290).

Nurses will receive 1.00 contact hours for participating in this course.

Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling

1.0 HOURS


Provider #50-290 This activity is approved for 1.00 contact hours.

Florida Board of Nursing CE

1.0 HOURS


Florida Board of Nursing CE Provider #: 50-290

Nurses will receive 1.00 contact hours for participating in this course.

American Nurses Credentialing Center

1.0 HOURS


Relias, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Nurses will receive 1.00 contact hours for participating in this course.

Association of Social Work Boards

1.0 HOURS


Relias, LLC, #1273, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education (ACE) program. Relias, LLC maintains responsibility for the program. ASWB Approval Period: 2/10/2018-2/10/2021. Social workers should contact their regulatory board to determine course approval for continuing education credits.

Course Delivery Format: Asynchronous Distance Learning-interaction includes quizzes with questions and answers, posttests. This module is Text-based.

Social workers participating in this course will receive 1.00 Clinical continuing education clock hours.

New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Social Work Unit

1.0 HOURS


Relias, LLC is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0009.

Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

As a provider of online, asynchronous education, some courses offered by Relias Learning are considered “self-study” under section 74.10(c)(2)(ii)(b)(4) of the Commissioner’s Regulations. The regulations limit self-study activities taken from a provider approved by the Education Department to no more than 12 hours in the 36-month registration period or one-third of the hours in a registration period other than 36 months.

Social workers will receive 1.00 continuing education hours for participating in this course. This activity is approved for 1.00 contact hours.

Georgia Board of Nursing

1.0 HOURS


Georgia Board of Nursing CE Provider #: 50-290

Nurses will receive 1.00 contact hours for participating in this course.

Missouri Health Care Association

1.0 HOURS


This on-line activity has been approved for 1.00 Administrative Hour(s) toward the Missouri continuing education requirement for nursing home administrators. Relias LLC offers courses approved by the Missouri Health Care Association, an approved training agency, TA-002-919, by the Missouri Board of Nursing Home Administrators. This activity is approved for 1.00 contact hours.

Florida Board of Nursing Home Administrators

1.0 HOURS


Course approved by the Florida Board of Nursing Home Administrators.
Provider # 50-290
NHA/RCAL
This activity is approved for 1.00 contact hours.

Oregon Department of Human Services

1.0 HOURS


This course is approved as continuing education by the Oregon Department of Human Services in accordance with state regulation 411-057-0140 for Assisted Living Administrators, Residential Care facility Administrators and Memory Care Communities within the State of Oregon. This activity is approved by Oregon Department of Human Services for 1.00 contact hours.

National Association of Long Term Care Administrator Boards (RCAL)

0.75 HOURS


This educational offering has been reviewed by the National Continuing Education Review Service (NCERS) of the National Association of Long Term Care Administrator Boards (NAB) and approved for 0.75 clock hours. If you have any feedback regarding the NAB approved continuing education programs, send your email to the following address: [email protected]

National Association of Long Term Care Administrator Boards (NHA)

0.75 HOURS


This educational offering has been reviewed by the National Continuing Education Review Service (NCERS) of the National Association of Long Term Care Administrator Boards (NAB) and approved for 0.75 clock hours. If you have any feedback regarding the NAB approved continuing education programs, send your email to the following address: [email protected]
Hours type - NHA: Administrative Hours

California Nursing Home Administrator Program - non-P type

1.0 HOURS


This educational offering is approved by the California Nursing Home Administrator Program (NHAP) for full credit as a course relating directly to duties, functions, or responsibilities of the nursing home administrator. Provider # CEP 1701; Course Approval # 1701001-6726. This activity is approved for 1.00 contact hours.

Course Details

Course Code: REL-SRC-0-LAD
Hours: 1
Type: Online Course
Content Expiration Date: 7/31/2019
Learning Objectives:
Describe two elements of proof in malpractice litigation.

Differentiate between compensatory and punitive damages.

Explain four intentional torts that a healthcare professional may be held liable for.

Describe four techniques you should use when documenting care to avoid legal issues.

Define malpractice and negligence as they relate to nursing and social work practice.

Outline:
Section 1: Introduction
A. About This Course
B. Learning Objectives
Section 2: Negligence and Malpractice
A. Nursing Practice
B. Social Work Practice
C. Importance of Documentation
D. Negligence and Malpractice
E. Review
F. Summary
Section 3: Proving Negligence and/or Malpractice
A. The Four Elements of Proof
B. Duty
C. Failure to Observe
D. Failure to Intervene
E. Failure to Protect
F. Breach in Standard Care
G. Causation or Intention
H. Damages or Harm
I. Review
J. Summary
Section 4: Intentional Torts
A. Examples of Intentional Torts
B. Abandonment
C. Assault
D. Battery
E. Breach of Promise
F. Conversion
G. Review
H. Fraud
I. Invasion of Privacy
J. Infliction of Emotional Distress
K. Defamation
L. False Imprisonment
M. Review
N. Summary
Section 5: Documentation
A. Criteria for Documentation
B. Charting Tips
C. The Do's
D. The Don'ts
E. Actions for Self-Protection
F. Documentation and the EHR
G. Review
H. Summary
Section 6: Conclusion
A. Summary
B. Course Contributors
C. Resources
D. References
E. Congratulations

Instructor: Lynn J. Grams, R.N., B.A., M.Ed.
Lynn Grams is a registered nurse in the state of Florida. She has an advanced degree in Adult Education with extensive experience in Nursing Education. At the Education Departments in Acute Care Hospital setting, she has been both instructor and department director since her arrival in Florida in 1974. Her past experience includes nursing supervision in acute care hospital setting as well. Prior to relocating to Florida she was employed as a staff nurse in ICU and Surgical units, Head Nurse of a Medical Surgical Unit, and two years as an instructor in a 3 year diploma nursing school. Disclosure: Lynn J. Grams, R.N., B.A., M.Ed. has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Expert Reviewer: Cheryl Swann, RN-BC, BSN, WCC, LNHA
Cheryl Swann, RN-BC, BSN, WCC, LNHA has worked in long-term care for 20 years. Mrs. Swann has worked in many positions including Director of Nursing, Medicare Nurse Coordinator and Nursing Home Administrator. Cheryl is certified in both Gerontological nursing and wound care. In the past, she has assisted in the operations of multiple nursing facilities, including staffing, payroll, public health concerns, family member issues, management of consultant relationships (e.g. pharmacy, dietary, etc.), and as an intermediary between long-term care facilities and doctors. Mrs. Swann worked closely with federal monitors and the Office of Inspector General in developing an effective Continuous Quality Improvement and compliance program in her organization. Mrs. Swann has presented nationally regarding effective Quality Assurance, Restraint Reduction, Wound Prevention, CMS Five Star Quality Rating System and Developing a Corporate Compliance Program. Her expertise includes staff training and development, Quality Assurance and Performance Improvement initiatives, and policy development. Disclosure: Cheryl Swann, RN-BC, BSN, WCC, LNHA has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Target Audience:
The target audience for this course is: entry level Nurses; entry level Professional Counselors; entry level Respiratory Therapists; entry level Social Workers; in the following settings: Post-Acute Care.
F Tags:
F842
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Course Delivery Method and Format
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
Relias has a grievance policy in place to facilitate reports of dissatisfaction. Relias will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias.
If you require special accommodations to complete this module, please contact Relias Support by completing the web form (https://www.relias.com/help) or by using the chat functionality.
All courses offered by Relias, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC.
All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
Accommodations
If you require special accommodations to complete this module, please contact Relias Customer Support here.