Outline

1. Setting the Stage
   1. Many people read medical records during a lawsuit
   2. Medical records are just as important as testimony
2. Legal and Ethical Implications of Documentation
   1. Purpose of the medical record in the courtroom
   2. “Get it right the first time”
   3. Standards of documentation
   4. How to recognize deviations from the Standard of Care
3. Risk Management & Documentation
   1. Incident reports
4. Admissible Forms of Nursing Documentation
   1. Common documentation mistakes
   2. Physician orders
   3. Assessment
   4. Plan of Care
   5. Medications
   6. Interventions
   7. Difficult, stressful or sensitive situations
   8. Patient education & responses
   9. Other formats of documentation
5. Nursing Charting Systems
   1. Narrative
   2. SOAP
   3. PIE charting
   4. Focus charting
   5. Charting by exception
   6. Considerations when using flow sheets
   7. Working with computerized medical records
6. Avoiding Legally Risky Documentation
   1. Credible evidence
   2. Recording events objectively
   3. Maintaining factuality & thoroughness
   4. Avoiding ambiguity
   5. Avoiding bias
   6. Abbreviations to avoid
   7. Late entries
   8. Personal notes
   9. Correcting errors
7. Documentation & Bioethical Dilemmas
   1. Code of ethics
   2. Telling the truth
   3. Universal principles of biomedical ethics
   4. ANA code for nurses
   5. End-of-life issues
   6. Informed Consent & Therapeutic Privilege
8. Malpractice and Documentation
   1. Absence of information
   2. Falsifying, tampering or covering up
   3. Consequences of tampering
   4. Forensic Document Examiner’s role in record review
9. Analyze a Real Case Scenario