Legal Aspects of Documentation for Home Care

Legal Aspects of Documentation for Home Care 

A client’s medical record is the most important and consistent source of information that all healthcare providers use to plan, provide, and evaluate care. What you document can and does directly reflect the quality of care that you provide and therefore must be factual, complete, timely, and detailed. It must also be compliant with reimbursement and regulatory standards. In this course, you will learn the purpose of good nursing documentation, best practices in documentation, documentation requirements for reimbursement, and the regulatory standards that affect your documentation. This course specifically addresses the issue of nursing documentation. In 2017, CMS issued updated Conditions of Participation, or CoPs, which govern the participation of home health agencies in the Medicare and Medicaid programs, with an implementation date of January 13, 2018. The intent of the updates is to reflect current best practices through a focus on client-centered care, client rights, and value and outcome-based care in an effort to promote high quality care for all, under all circumstances, in the home health arena. This course reflects those changes

$20.00

Hours: 1.00
REL-SRC-0-LADHC-V2

Certificates

Certificates provided by accrediting body (8 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.

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.

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 Nursing

1.0 HOURS


Florida Board of Nursing CE Provider #: 50-290

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

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.

South Carolina Board of Nursing

1.0 HOURS


This program was approved by the South Carolina Board of Nursing Approved Continuing Education Program (CE provider #50-290) CE Broker Course # 20-[Custom_Code]

Texas Health and Human Services Commission

1.0 HOURS


Texas HHSC has determined that Relias Learning’s submitted training meets or exceeds the minimum standards for HCSSA administrator training in the following categories: Licensed and Certified Home Health (L&CHH), Hospice. Texas HHSC also recognizes Relias Learning provides continuing education for administrators and alternate administrators. This activity is approved for 1.00 contact hours.

West Virginia Board of Registered Nursing

1.0 HOURS


Course Details

Course Code: REL-SRC-0-LADHC-V2
Hours: 1
Type: Online Course
Content Expiration Date: 12/31/2020
Learning Objectives:
Identify why good documentation is necessary in home care.
Use documentation best practices to write compliant documentation.
Describe how reimbursement requirements and regulatory standards affect documentation in home care.

Outline:
Section 1: Introduction A. About This Course B. Learning Objectives Section 2: Purpose of Documentation A. An Astounding Fact B. Obstacles to Good Documentation C. Form of Communication D. Regulatory Standards E. Reimbursement Requirements F. Malpractice G. Quality Improvement H. Review I. Summary Section 3: Documentation Best Practices A. Compliant Documentation B. Methods for Documenting C. Timeliness D. Accuracy and Completeness E. Writing Clear Notes F. Client Refusal G. Incident Reports H. Wound Documentation I. Wound Photography J. Electronic Medical Records K. Handwritten Medical Records L. Other Practices M. Review N. Summary Section 4: Reimbursement and Regulations A. HH PPS B. Medicare Reviews C. Required Documentation D. The Face-to-Face Encounter E. Coverage for Skilled Nursing F. Observation and Assessment G. Managing the POC H. Teaching and Training I. Wound Care J. Venipuncture K. Other Nursing Services L. Conditions of Participation M. Client Rights N. Plan of Care O. Professional Standards P. Coordination of Care Q. Comprehensive Assessment R. Drug Regimen Review S. Review T. Summary Section 5: Conclusion A. Summary B. Course Contributors C. Resources D. References E. Congratulations!

Staff Writer: Jennifer Moore, RN-BC, CDP, WCC
Jennifer Moore, RN-BC, CDP, WCC started working in the senior care industry in 2000. She is a certified Gerontological Nurse, a Certified Dementia Practitioner, and Wound Care Certified. She has held positions including MDS Coordinator, Director of Nursing, Medicare Nurse Coordinator, Nurse Consultant, Area Manager, and Director of Quality Assurance. Her overall responsibility within each of these positions was to ensure residents received the highest quality of care. This included active participation in quality improvement initiatives, review of clinical records to identify areas of weakness, corroboration with the medical director to institute policies and procedures for resident care, and staff education/training. Additionally, she was responsible for maintaining an effective compliance program under a Quality of Care Corporate Integrity Agreement with the Office of Inspector General for a period of five years. She currently serves as the Director of Curriculum Design & Research for Relias. Within this position, her responsibility is to oversee the development of online training modules across the healthcare continuum. She has served as the subject matter expert for courses on re-hospitalization, clinical skill reviews, leadership, management, and various OSHA and regulatory compliance topics. In addition, she has presented at various state conferences on mandatory compliance, quality assessment and assurance (QA&A), and quality assurance and performance improvement (QAPI).  Disclosure: Jennifer Moore, RN-BC, CDP, WCC has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Expert Reviewer: Barbara Knott, RN, MPA, ACHCE
Ms. Knott has 36 years of experience in healthcare, with the last 34 years spent in the home care field. She has been responsible for agency regulatory and accreditation compliance as well as quality assurance programs for home health and hospice. In her current position, she has oversight of the financial, operational, and quality performance of multiple home healthcare providers. Ms. Knott has received certification as an Advanced Certified Home Care Executive. Disclosure: Barbara Knott, RN, MPA, ACHCE 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: Nurses; in the following settings: Home Health.
G Tags:
G1008, G1010, G1012, G1014, G1016, G1024, G406, G408, G410, G412, G414, G420, G424, G426, G428, G432, G434, G438, G440, G444, G450, G484, G490, G510, G522, G526, G528, G530, G532, G534, G536, G538, G540, G570, G572, G574, G586, G588, G590, G600, G602, G606, G610, G700, G702, G704, G706, G708, G710, G712, G714, G716, G718, G724, G726, G728, G730, G750, G982, G984, G986
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.
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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.