Documentation Hazards for Geriatric Patient Care: Minimal Care Expectations & Regulatory Standards – Rachel Henderson

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Exploring the Essential Features of “Documentation Hazards for Geriatric Patient Care: Minimal Care Expectations & Regulatory Standards – Rachel Henderson”

Knowing what to chart, how to chart, and when to chart is half the battle of charting regardless of the clinical setting.  Rachel Cartwright-Vanzant Ph.D., MS, LHRM, CCRN-K, has extensive expertise testifying and through work as a risk manager. She will delve into the very latest documentation categories that lend themselves to litigation and highlight the risks specific to the care of geriatric patients, including attention to minimal care expectations and regulatory standards.

Speaker

Rachel Henderson, PhD, MS, RN, HCRM
 
Rachel Henderson, PhD, MS, RN, HCRM, is an expert speaker on topics focused on legal aspects of healthcare, nursing documentation, and regulatory compliance. Her 22 years as a legal nurse consultant, inpatient clinical nurse specialist and healthcare risk manager (HCRM) bring life to her presentations by sharing real case scenarios. She is a member of the National Speakers Association (NSA) and past president of the Florida Speakers Association (FSA). She is a published author in peer-reviewed journals and textbooks. In addition to owning a medical and legal consulting business, she has her PhD in Public Policy and Administration: Law and Policy. Rachel works with law firms and healthcare organizations, evaluating medical records for compliance with standards of care and applicable regulations. She has been an expert witness for medical negligence cases for both the plaintiff and the defense.

Speaker Disclosures:
Financial: Dr. Rachel Henderson has employment relationships with Medical Legal Concepts, Florida SouthWestern State College, and Palm Beach State College. She receives royalties as a published author. Dr. Henderson receives a speaking honorarium and recording royalties from PESI, Inc. She has no relevant financial relationships with ineligible organizations.
Non-financial: Dr. Rachel Henderson is a member of the American Association of Critical Care Nurses, the American Society of Healthcare Risk Managers, and the American Society of Professionals in Patient Safety.

Objectives

1. Determine how scribes are effectively used in clinical practice. 
2. Differentiate between state staffing and federal staffing requirements.  
3. Choose an implementation practice to manage polypharmacy. 
4. Apply the standards of pain assessment to medical record entries. 
5. Analyze physical findings that could represent forensic evidence.   
6. Determine if a patient has malnutrition from medical record entries. 
7. Analyze the current issues that may violate resident rights in long term care. 

Outline

Medical Scribes

• Aide in managing documentation of physicians 
• Charting estimated requirements 
• Qualifications of scribes 
• Accountability of medical record entries and treatment plan 

Handling of Informed Consent

• Competence and capacity 
• Four dimensions of competence 
• Biological age compared to numerical age 
• Logical considerations 

Frailty Screening Tools

• Contributes to rising health care cost 
• Frailty measurement instruments 
• Delaying declines and promoting resilience outcome 

Nurse Staffing Standards  

• Staffing requirements 
• Basic care and resident rights 
• Clinical measures of poor quality 
• State deficiencies 

Polypharmacy Management

• Coordination of multiple prescribers 
• Brown Bag review 
• Medication reconciliation  
• Mediation appropriateness 
• Psychotropic medication specific concerns 

Pain Assessment

• Limitations to accurate assessment of pain 
• Guidelines for pain management 
• Regulatory standards 

Nutrition Screening

• Identify patients with malnutrition 
• Screening tools 

Physical Findings in Injured Older Adults

• Documentation tools for elder abuse and neglect 
• Improve documentation of potential forensic injuries 
• Online resources 

Ethical Issues in Long Term Care

• Rights of residents in nursing homes 
• Substance use 
• Resident-to-resident aggressive behavior 
• Staff-resident abuse 

Target Audience

• Nurses
• Nurse Practitioners
• Clinical Nurse Specialists
• Physician Assistants
• Physicians
• Physical Therapists
• Physical Therapist Assistants
• Occupational Therapists
• Occupational Therapy Assistants
• Speech Language Pathologists
• Social Workers
• Nursing Home Administrators

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