“If you don’t write that, you could lose your license,” or “If you write that, you could lose your license.” This was something I heard during my entire nursing career and I never really knew what it meant. I was the nurse who was called into the office to explain an entry, clarify a comment, or “fix” something that had already been noted. My thought was, “if you just tell me what I’m supposed to chart, I’ll do it.”
In addition to supervisor or facility expectations, there are requirements now in place for electronic charting by the Center for Medicare and Medicaid Services (CMS). In addition, healthcare is highly regulated and full of reimbursement woes, which often are connected with the documentation. What’s a nurse to do…? Rosale Lobo, PhD(c), MSN, RN, CNS, LNCC, has the answers!
Learn the meaning of being a non-fiction story teller - nurses have been voted the most trusted professionals for years because we are truth tellers. We are educated to care for our patients with compassion and ethics, so why has it become difficult to chart according to our personal belief system. Learn the truth behind documentation standards.
Charting for innocence or guilt - it is no secret that charting can lead to a trip to court but how does that actually happen. How does this path become something nurses fear? This 3-day boot camp will take you down the path to litigation and demonstrate why certain actions or inactions could jeopardize your chances of appearing innocent.
Did you deviate from the standard of care? How does a person deviate from the standard of care if there is no one there to witness it? Who determines that a nurse has deviated from the standard of care? Three days of intense learning about nursing documentation and litigation will transform the way you think about your nursing practice and the way you document the care you provide.
This class is a must for all nurses. It is long overdue. You will definitely return to work with increased confidence to reduce your own professional risk.