Patient Chart Reviews – with Actual Documentation Mistakes – Rachel Henderson

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Exploring the Essential Features of “Patient Chart Reviews – with Actual Documentation Mistakes – Rachel Henderson”

Patient safety is one of the paramount priorities in clinical settings. Patient safety is one of many reasons formal clinical documentation improvement programs were developed. The best way to prevent a documentation disaster is by recognizing the most frequent documentation errors and putting procedures in place to prevent them. The top four documentation mistakes are mixed messages, misuse of copy and paste in the electronic health record, incomplete or missing documentation, and misplaced documentation. High-quality patient documentation is crucial for ensuring quality care, continuity of care, and patient safety. Learning from the mistakes of others is effective in changing documentation practice patterns.

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. Compare and contrast a medical error and a medical mistake.
2. Discuss components of a medical malpractice claim.
3. List outcomes associated with proper medical documentation.
4. Explain common errors in medical records.
5. Analyze documentation errors and mistakes and cite appropriate corrective actions.

Outline

Medical Errors v. Medical Mistakes

• differentiate between medical errors and medical mistakes
• Examples of medical errors
• Examples of medical mistakes
• What is medical malpractice?

What is Medical Malpractice?

• Key elements of a malpractice cause of action lawsuit
• Define Standard of Care
• Acts of omission
• Liability Exposure

Proper Medical Documentation

• Communicate with other medical personnel
• Minimize exposure to risk management
• Documents, quality measures, and CMS hospital indicators
• Provides proper reimbursement

Common Errors in Medical Records

• Errors in transcription
• Misuse of abbreviations
• Insufficient documentation
• Ignoring crucial information
• Incorrect information entry
• Other medical errors

Examples of Documentation Errors and Mistakes

Target Audience

• Nurses
• Nurse Practitioners 

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