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Proper Documentation to Accurately Reflect Patient Progress and Enhance Patient Care

Learn to identify resources and understand methods for documenting patient condition and progress.

The proliferation of specialized practice settings in conjunction with proliferation of reimbursement requirements, the great expansion of best practices, guidelines for a multiplicity of required algorithms for governmental regulations, the expansion of ICD codes in the ICD-10, CMS requirements, to name just a few, have greatly impacted what we must document concerning patient condition, type of care, progress or lack thereof. Denial of services and payment due to failure to adequately document can be devastating to patient and practitioner alike. This topic will help you identify and understand the problem, resources and methods for documenting patient condition and progress to ensure the continuation of appropriate services for the patient and reimbursement for the providers of service. Failure to use 'terms of art' and provide all necessary information is common and delays service and payment, especially during the inception of new systems. In addition to identification and understanding these issues, you will hear specific suggestions for selected practice areas as examples.

Runtime: 67 minutes
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Over 31 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Agenda

Fundamentals of Documentation in the Electronic Medical Record

Most Common Hospital Admission Diagnoses and the Related Outcome Measures for Each

Legal Implications of Documentation in the Electronic Medical Record

This Continuing Educational Activity was approved by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Participants may receive up to 1.10 contact hours for completing this program.

To receive a certificate of successful completion, you are required to complete and return an evaluation form. Planning Panel members are Megan Farrow, MSN, RN, Katie Morales, PH.d, RN, CNE, Pam Johnson, MSN, RN, CCRN, Michelle Shepherd, B.A in Psychology and C.E. Coordinator and Christina M. Schuch, CE Specialist. There are no conflicts of interest to report. There was no commercial support received for the planning of this program. No endorsement of products will occur at this program.

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Over 31 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Credits

OnDemand Webinar

This course was last revised on January 3, 2018.

Call 1-866-352-9540 for further credit information.

  • RN - ANCC 1.1
     
  • This Enduring Material was approved by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Participants receive 1.1 contact hours for this program. To receive a certificate of successful completion, you are required to complete and return an evaluation form. Planning Panel Members are: Michelle Shepherd. There are no conflicts of interest to report. There was no commercial support received for the planning of this program. No endorsement of products or off-label use will occur at this program.
     

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Why Lorman?

Over 31 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Faculty

Megan Farrow, MSN, RN

Megan Farrow, MSN, RN

Berry College

  • Clinical instructor of Nursing at Berry College
  • Critical Care nurse since 2009 in Level 2 Trauma Center, Cardiac ICU, Neuro ICU, Med/Surg ICU
  • 4 years of education experience in clinical, classroom and simulation
  • Podium presentations include 2017- Innovation in Teaching Conference, University of Georgia, Teaching for Learning: It’s All Fun and Games; 2016- Georgia Association of Nurse Educators, Jekyll Island, GA, An Innovative Approach to EBP
  • Member of Sigma Tau Delta English Honor Society, Phi Kappa Phi Honor Society, Georgia Association of Nurse Educators and Georgia Simulation Association
Katie Morales, Ph.D., RN, CNE

Katie Morales, Ph.D., RN, CNE

Berry College

  • Assistant professor of Nursing at Berry College
  • 32 years’ experience as a nurse, 12 years’ experience as a legal nurse consultant, and 6 years’ experience in education
  • Professional presentations on nursing and education topics
  • Written several publications related to nursing and nursing education: Active learning strategies to enhance nursing students’ knowledge of pharmacology. Nursing Education Perspectives, 38 (2). 100-102 doi: 10.1097/01.NEP.0000000000000085; Morales, K. (2017). QSEN Teaching strategy: Using an aquarium and pump to demonstrate cardiac function. Retrieved from http://qsen.org/qsen-teaching-strategy-using-an-aquarium-and-pump-to-demonstrate-cardiac-function/; Morales, K. (2016). Use of an Aquarium and Pump to Demonstrate Cardiac Function. Nursing Education Perspectives, 37 (6). 354–355 doi: 10.1097/01.NEP.0000000000000084; Morales, K. (2017). Politics and nursing: Get Involved. Georgia Nursing, (77) 1. P. 4 2009-Present Contributor Nursetogether.com
  • 2009-2011 Subject Matter Expert Nurses Network; 2016 Pharmacology Made Insanely Easy eighth edition; 2016 Nursing Made Insanely Easy eighth edition; 2016 Keeping It Real! Simplified second edition; 2011 Emergency Nursing Bible fifth edition; 2010 Legal Nurse Consulting: Principles & Practice third edition
  • Member of Phi Kappa Phi, Golden Key International Honour Society, Association for General & Liberal Studies and Graduate Nursing Student Academy
  • Ph.D. degree, Georgia Baptist College of Nursing of Mercer University; M.S. degree in nursing education, Grand Canyon University; B.S. degree in nursing, University of Phoenix; associate degree in nursing, Columbus State University
  • Can be contacted at KMorales@Berry.Edu, 706-889-2915 or on Twitter® @KMorales
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Product ID: 399806
Published 2018
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