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Documentation: The Legal Side
As a professional nurse, you are expected to be familiar with many aspects of care. You are not exempt from malpractice or negligence claims because you were following orders. You are responsible for assessing, planning, implementing, and evaluating appropriate nursing care. What you document can and does reflect the care provided and the outcomes of that care. Documentation that is factual, complete, timely, and detailed is required. In this course, you will learn about concepts and rules regarding documentation in the medical record. Legal aspects to be aware of while practicing will also be discussed. The goal of this course is to educate nursing professionals in post-acute care settings about the legal implications of documentation.
Discuss malpractice, negligence, and compensatory and punitive damages as they relate to healthcare. Explain four intentional torts that a healthcare professional may be held liable for. Describe four documentation techniques to use to avoid legal issues.
HCAHPS: Transitions of Care and Discharge
Improving hospital processes surrounding discharge and transitions of care can reduce adverse events and readmissions. Process improvements may also lead to better patient adherence to the treatment plan and their overall experience with care. Healthcare professionals must understand care coordination and transitions of care and how they impact HCAHPS survey results.
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a national standardized survey required for hospitals participating in Centers for Medicare & Medicaid Services (CMS) programs. Survey results are linked to hospital reimbursement from CMS.
Identify the impacts of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Hospital Value-Based Purchasing (HVBP) programs on healthcare organizations.
Categorize transitions of care, care coordination, and discharge planning.
Select strategies to improve interprofessional teamwork.
Medical Record Documentation and Legal Information for CNAs
Documenting care is just as important as providing care. This course discusses the purpose of the medical record and documentation. It also describes documentation practices and legal standards that affect the certified nursing assistant.
This course provides direct care workers in post-acute care education on documentation and legal aspects of care.
Discuss the purpose of the medical record and documentation.
Identify at least two documentation practices used to avoid errors.
Explain the legal standards that affect the certified nursing assistant.
Preventing and Handling Crisis Situations
Healthcare professionals often encounter patients experiencing agitation or displaying hostile behavior during their careers. De-escalation is a set of approaches and techniques used to assist patients in self-calming to avoid incidents of harm to self, others, or property. Professionals should understand escalation and physiological responses to threats. After determining the risk of escalation, healthcare professionals can use various aspects of verbal communication, such as tone and pitch, and nonverbal communication skills to defuse potentially hostile situations and apply the least restrictive interventions.
Describe what de-escalation is and why it is important.
Recall how to use de-escalation to prevent a crisis from developing.
Indicate specific approaches you can use during a crisis to help individuals return to pre-crisis levels of functioning and prevent harm.