This program will cover the basics of documentation, the principles of which are set out by the American Nurses Association (ANA). The expectations from the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission (TJC) regarding documentation will be discussed in this webinar. Additionally, legal implications surrounding documentation will be addressed.
Included in the discussion will be case studies that present documentation and how the content, or lack thereof, resulted in a decision either for the health care provider or the plaintiff.
Laura A. Dixon, BS, JD, RN, CPHRM
Laura A. Dixon served as the director of risk management and patient safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as the director, facility patient safety and risk management and operations for COPIC from 2014 to 2020. In her role, she provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states.
Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the director, Western region, patient safety and risk management for The Doctors Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States
As a registered nurse and attorney, Dixon holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.
At the conclusion of this session, participants should be able to:
Recall ANA’s principles for nursing documentation.
Describe the regulatory and professional requirements and expectations for documentation.
Recite the basic requirements for documentation of clear, accurate, timely and complete.
Explain the importance of documentation in preventing and/or defending medical malpractice cases.
By attending From the Frontlines: Why Documentation Is So Important Webinar offered by Georgia Hospital Association, participants may earn up to 1.5 ACHE Qualifying Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation. Attendees who wish to have the hours applied toward ACHE Qualifying Education credit must self-report their participation by logging into their MyACHE account and selecting ACHE Qualifying Education Credit.