Legal Aspects of Home Care Documentation
A medical record is the most important and consistent source of information that healthcare providers use to plan, provide, and evaluate care. In this course, you will learn about the purpose of documentation in home healthcare and documentation best practices, as well as the reimbursement requirements and regulatory standards that affect your documentation. The goal of this educational program is to provide nursing professionals in home healthcare with instruction regarding documentation.
A medical record is the most important and consistent source of information that healthcare providers use to plan, provide, and evaluate care. In this course, you will learn about the purpose of documentation in home healthcare and documentation best practices, as well as the reimbursement requirements and regulatory standards that affect your documentation. The goal of this educational program is to provide nursing professionals in home healthcare with instruction regarding documentation.
American Nurses Credentialing Center
In support of improving patient care, Relias LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Nurses will receive 1.00 Nursing Contact Hours after successfully completing this course.
Arkansas State Board of Nursing
Arkansas State Board Of Nursing Approved Continuing Education program (CEBroker Provider #50-290).
Nurses will receive 1.00 contact hours for participating in this course.
California Board of Registered Nursing
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
District of Columbia Board of Nursing Approved Continuing Education program (CEBroker Provider #50-290).
Nurses will receive 1.00 contact hours for participating in this course.
Florida Board of Nursing
Florida Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Georgia Board of Nursing
Georgia Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Kentucky Board of Nursing
Kentucky Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Mississippi Board of Nursing
Mississippi Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
New Mexico Board of Nursing
New Mexico Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
North Dakota Board of Nursing
North Dakota Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
South Carolina Board of Nursing
South Carolina Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Texas Health and Human Services Commission
Texas HHSC has determined that Relias' submitted training meets or exceeds the minimum standards for HCSSA administrator training in the following categories: Licensed Home Health (LHH), Licensed and Certified Home Health (L&CHH), Personal Assistance Services (PAS), Hospice. Texas HHSC also recognizes Relias provides continuing education for administrators and alternate administrators. This activity is approved for 1.00 contact hours.
West Virginia Board of Registered Nursing
West Virginia Board of Registered Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Outline the purpose of documentation in home healthcare.
Explain how to use best practices to create compliant documentation.
Describe how reimbursement requirements and regulatory standards affect documentation in home healthcare.
Outline:
Section 1: Introduction
About This Course
Learning Objectives
Documentation Matters
Obstacles to Good Documentation
Form of Communication
Regulatory Standards
Reimbursement Requirements
Malpractice
Quality Improvement
Review
Summary
Compliant Documentation
Methods for Documenting
Timeliness
Accuracy and Completeness
Writing Clear Notes
Patient Refusal
Incident Reports
Wound Documentation
EMRs
Handwritten Medical Records
Abbreviations
Other Practices
Review
Summary
Patient-Driven Groupings Model
Medicare Reviews
Required Documentation
The Face-to-Face Encounter
Coverage for Skilled Nursing
Observation and Assessment
Managing the POC
Teaching and Training
Venipuncture
Home Infusion Therapy
Conditions of Participation (CoPs)
Patient Rights
Plan of Care
Professional Standards
Coordination of Care
Comprehensive Assessment
Drug Regimen Review
Review
Summary
Section 5: Conclusion
Summary
Course Contributor
Resources
References
Congratulations!
Jennifer has over 30 years of clinical and teaching experience, and her areas of expertise are critical care and home health. She is certified as an OASIS Specialist- Clinical (COS-C) and is a Curriculum Designer in post-acute care for Relias. She earned her Bachelor of Science in Nursing from The University of Virginia in 1993 and her Master of Science in Nursing from The University of North Carolina, Greensboro in 1996. Her professional practice in education is guided by a philosophy borrowed from Florence Nightingale’s Notes on Nursing, “I do not pretend to teach her how, I ask her to teach herself, and for this purpose, I venture to give her some hints.”
The target audience for this course is: Nurses; in the following settings: Post-Acute Care.
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.
If you require special accommodations to complete this module, please contact Relias Customer Support here.
