From the Frontlines: Why Documentation Is So Important
Automated Live

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Automated Live   Publish:   2021-10-06   |   09:21 AM - EST   |   2.2 hrs
BRIAN L TUTTLE

BRIAN L TUTTLE

Education:-   Certified HIPAA Professional

Brian L Tuttle, CPHIT, CHP, CBRA, Net+, A+, CCNA, MCP is a Certified Professional in Health IT (CPHIT), Certified HIPAA Professional (CHP), Certified HIPAA Administrator (CHA), Certified Business Resilience Auditor (CBRA), Certified Information Systems Security Professional (CISSP) with over 18 years' experience in Health IT and Compliance Consulting. With vast experience in health IT systems (i.e. practice management, EHR systems, imaging, transcription, medical messaging, etc.) as well as over 18 years’ experience in standard Health IT with multiple certifications and hands-on knowledge, Brian serves as compliance consultant and has conducted onsite and remote risk assessments for over 1000 medical practices, hospitals, health departments, insurance plans, and business associates throughout the United States.   

Description: 

This program will cover the basics of documentation, including the “why” and “what”.  Principles of the documentation set out by ANA, expectations from CMS and Joint Commission regarding documentation will be covered.  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 either a decision for the healthcare provider or the plaintiff.

Objectives:-

  • Recall ANA’s principles for nursing documentation.
  • Describe the regulatory and professional requirements and expectations for documentation.
  • Recall the basic requirements for documentation of clear, accurate, timely, and complete.
  • Recall the importance of documentation in preventing and/or defending medical malpractice cases.

Who Should Attend?

  • Clinical leads – charge nurses
  • Nursing Educators
  • Managers
  • Compliance officers
  • Patient Safety/Risk Managers
  • Legal Counsel
  • Nurses
Recall ANA’s principles for nursing documentation. Describe the regulatory and professional requirements and expectations for documentation. Recall the basic requirements for documentation of clear, accurate, timely, and complete. Recall the importance of documentation in preventing and/or defending medical malpractice cases.

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