Electronic Medical Records

Cheryl Carver's picture
safety net

By Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

Substandard documentation tops the list of mistakes for long-term care facilities. It involves "all hands in the chart" so to speak. This encompasses all disciplines, from the nursing assistant to the physician. Discrepancies and gaps in documentation put your facility at risk of litigation. Impeccable documentation is essential in defending any case. Your facility must have a "safety net" in place. This "safety net" consists of educating staff about the importance of timely and detailed documentation not only for the facility, but for their license. Often times, clinicians are not aware of the legal repercussions of their actions. Surveyors will also consider other related Federal Tags (F-Tags) during investigations for compliance.

Janis Harrison's picture

By Janis E. Harrison, RN, BSN, CWOCN, CFCN

As I was pushed from the room where my husband was coding, I was met by a tiny little nun, we'll call Sister. She tried to move me to a waiting area nearby but I knew I was not going to step away from the door. They had not listened to or assessed my husband during a very concerning time and he was supposed to be in post-op recovery.

Paula Erwin-Toth's picture

By Paula Erwin-Toth MSN, RN, CWOCN, CNS

Part 4 in a series discussing the challenges and opportunities in patient/family education
For Part 1, Click Here
For Part 2, Click Here
For Part 3, Click Here

Paula Erwin-Toth's picture

by Paula Erwin-Toth MSN, RN, CWOCN, CNS

Part 3 in a series discussing the challenges and opportunities in patient/family education
For Part 1, Click Here
For Part 2, Click Here

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Glenda Motta's picture

By Glenda Motta RN, MPH

Recently, I attended the WOCN Mid-Atlantic Regional conference. There, a nurse attorney discussed strategies to limit liability and improve patient care. The Maryland Patient Safety Law requires that hospitals report all Level I events to the state Office of Health Care Quality (OHCQ). The penalties for failing to meet these requirements can include revocation of the hospital’s license or a fine of $500 per day.