DOCUMENTATION AND COMMUNICATION: FORENSIC ISSUES FOR HEALTHCARE IN THE DIGITAL ERA
COURSE DESCRIPTION: This forensic documentation and communication course is designed to assist nurses in understanding recent changes in nursing documentation effected by revised practice standards, new regulatory guidance and emerging technology in the digital era. The widespread use of computer charting, the increase of automated retrievals and downloads of patient information to the hospital information system, tracking technology and the use of personal communication devices have revolutionized patient record-keeping. The technological advances have streamlined many types of routine documentation, but nurse-generated, written documentation must be more precise than ever before to ensure that it coincides with computer-generated and time-stamped information that is continuously being recorded and transmitted. This course prepares nurses for the challenges and opportunities associated with the "new age" of digital recording, and will illustrate important forensic (legal) implications inherent in clinical documentation.
OBJECTIVES: Upon completion of this course, the student will be able to:
- Describe 3 JCAHO requirements which relate to nursing documentation.
- Relate quality and precision of documentation to hospital reimbursement including Medicare, Medicaid and other third-party payers.
- State best practices for documenting content relating to patient safety.
- Understand implications of nursing documentation that relate to sentinel event reporting and investigation.
- Select statements that describe recommended procedures for inserting late entries and correcting mistaken entries in medical records.
- Explain how computerized charting and automatic capture of patient's physiological data impacts written nursing documentation.
- Identify the assets and limitations of nursing documentation in regards to its contributions in the prosecution or defense of a forensic case.
- Select preferred or 'best practice' statements when presented pairs of statements describing a clinical event.
- Outline the legal steps in regard to discovery of documentary evidence associated with a hospital adverse event or lawsuit.
- List 4 indicators of tampering or spoliation of medical records that forensic nurses could detect when performing a patient-centered investigation.
CE CONTACT HOURS: 10
COURSE FEE: $80 (Group rates are available upon request. Contact .)
WHO MAY TAKE THIS COURSE: Registered nurses, licensed vocational nurses and other persons who care for and manage the elderly in a hospital, assisted living facility, convalescent hospital or home environment.
AVAILABILITY: Upon Demand
PRESENTATION METHOD: This downloadable course is in PDF format.
TEACHING METHOD: This is a self-paced course.
DURATION: All course requirements must be completed within 6 months of enrollment.
METHOD OF COURSE GRADING: Pass/fail grading system. Course examination is multiple choice and true/false statements. When a score of less than 70% is received, the examination may be taken one time without charge. Contact: for further information regarding additional retakes of the examination.
METHOD OF COURSE EVALUATION: After successful completion of the course examination, a course evaluation must be submitted to .
CERTIFICATE OF COMPLETION: Upon completion of the course content, examination with a passing grade of 70% and evaluation, student will receive a certificate of completion.
REQUIRED COURSE MATERIALS: All readings have been incorporated in the coursework materials.
SUGGESTED COURSE MATERIALS: There are no suggested course materials.
OTHER RELATED COURSES: Forensic Evidence Collection in the Clinical Setting, Forensic Evidence Collection in the Emergency Department, Chain of Custody.
AUTHORíS BIOGRAPHICAL INFORMATION: Janet Barber Duval, MSN, RN, Colonel, USAF NC, (Ret)
Course Procedure from start to completion.
All courses and materials are based on United States laws and regulations unless otherwise noted. Laws vary from state to state.