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NARRATIVE DOCUMENTATION: Protecting Your Patients, Practice, and License in the Information Age

This course provides direct-care nurses with a review of the principles of accurate and responsible recordkeeping that facilitates and enhances interdisciplinary communication, whether the format for recording patient care data is paper based or computer based. Included is an overview of selected documentation systems currently in use, including the source-oriented record; the problem-oriented medical record; focus charting; charting by exception; and computerized/electronic medical record (EMR) templates.

The Joint Commission’s (Hospital) National Patient Safety Goals and relevant federal Centers for Medicare and Medicaid Services (CMS) regulations and payer policies for documentation will be outlined together with professional standards of documentation. The course includes a discussion of the impact of EMRs on nursing practice and the rationale for pursuing individual and collective patient advocacy strategies, as circumstances require, to prevent override of the registered nurse’s independent professional clinical judgment by software systems, sequential decision-making formats, and proprietary automated documentation/clinical practice guidelines.

Thursday, July 17, 2014

Monday, July 31, 2014

This CE course is free to NNOC/NNU members. Join NNOC/NNU

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