Posts Tagged ‘Defensive Documentation’

The Great (Legal) Debate About Turn and Reposition Documentation

Friday, April 7th, 2017

Nancy Collins, PhD, RDN, LD, FAPWCA, FAND

Documentation of turning and repositioning often leads to legal problems as some healthcare providers chart by exception and others chart at the point of care.

The Great (Legal) Debate About Turn and Reposition Documentation

 

“The hospital never turned the patient, and therefore the patient suffered a serious pressure injury,” declared the plaintiff attorney. The defense team shot back, “Whoa. Slow down. Never is long time, and of course we turned the patient.” How can a basic care intervention such as turning and repositioning have two totally opposing views?

(more…)

If it Wasn’t Documented, It Wasn’t Done! Documentation Woes! Part 3

Wednesday, October 14th, 2009

http://www.wcei.net . Cindy Broadus RN continues her discussion about Proper and Defensive Documentation.

In a continuation of the discussion of the medical record, Cindy has a unique position and speaks from experience. As a CLNI (Certified Legal Nurse Investigator) and LNC (Legal Nurse Consultant), she shares with us actual instances and common mistakes our peers often make while documenting. Listen in and watch as Cindy continues her presentation to the attendees at the Wild On Wounds Conference in Las Vegas Nevada

For more information about becoming Wound Care Certified, please visit http://www.wcei.net

Please visit WoundSeminar.com for more information about next year’s Wild On Wounds Conference being held in Las Vegas NV

If it Wasn’t Documented, It Wasn’t Done! Documentation Woes! Part 2

Wednesday, October 14th, 2009

http://www.wcei.net . Cindy Broadus RN discusses Defensive Documentation.

The medical record is considered to be the most reliable source for determining what happened. It is a legal document, yet not always treated as such. With litigation lurking around the corner for every healthcare professional, we, as Wound Care Certified professionals, need to make sure our documentation is complete, concise and correct. Come on it and let’s talk about correct terms, techniques, and steps it will take to keep you out of trouble.

For more information about becoming Wound Care Certified, please visit http://www.wcei.net

If it wasn’t Documented, It wasn’t done!

Sunday, October 11th, 2009

How many times have we all heard, “If it wasn’t documented, it wasn’t done”? Far too often, we’re sure. Seriously, we as clinicians should take note of our documentation practices. Below is a short clip (Part 1 of 4) in which WCEI’s own Cindy Broadus RN, presented to the attendees at the Wild On Wounds Conference in Las Vegas NV in September. Her session was titled “If It Wasn’t Documented, It Wasn’t Done! Documentation Woes”.

Here was the description of the session: The medical record is considered to be the most reliable source for determining what happened. It is a legal document, yet not always treated as such. With litigation lurking around the corner for every health care professional, we, as Wound Care Certified professionals, need to make sure our documentation is complete, concise and correct. Come on it and let’s talk about correct terms, techniques, and steps it will take to keep you out of trouble.

Cindy always knocks it out of the park! Great job Cindy!

Wound Care Certification: Defensive Documentation

Sunday, June 28th, 2009

Practicing as a Wound Care Certified nurse or professional has its challenges. Not only do we have the challenge of taking care of complex patients and the wounds they incur. We also have the challenge of protecting ourselves through proper and defensive documentation. We should always document the services we are providing accurately. We should always be taking credit for the services we provide and thus properly documenting is defensive documentation. Far too often we become complacent in our day to day jobs and say to ourselves “I’ll just document that later”. Sometimes that “later” becomes never! We should all practice good documentation habits, not only for reimbursement purposes, but for defensive purposes. Below is a short video in which Cindy Broadus RN and Nancy Morgan RN discuss the importance of defensive documentation.