Patient Chart Reviews – with Actual Documentation Mistakes
- Speaker:
- Rachel Henderson, PhD, MS, RN, HCRM
- Duration:
- 2 Hours 05 Minutes
- Format:
- Audio and Video
- Copyright:
-
Aug 24, 2023
- Product Code:
- POS078616
- Media Type:
- Digital Seminar
Description
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.
Credit
Planning Committee Disclosure - No relevant relationships
All members of the PESI, Inc. planning committee have provided disclosures of financial relationships with ineligible organizations and any relevant non-financial relationships prior to planning content for this activity. None of the committee members had relevant financial relationships with ineligible companies or other potentially biasing relationships to disclose to learners. For speaker disclosures, please see the faculty biography.
NOTE: Tuition includes one free CE Certificate (participant will be able to print the certificate of completion after passing the online post-test (80% passing score) and completing the evaluation). Instructional methods will include PowerPoint, didactic lecture, and others.
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For Planning Committee disclosures, please see the statement above. For speaker disclosures, please see the faculty biography.
Earn up to 2.0 CE hours. Please see below, for more details, as credit amounts vary by state and profession.
PESI, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation. Nurses completing these self-study materials will earn 2.0 contact hours. Expires: 08/08/2026.
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PESI, Inc. is an approved provider by the Florida Board of Nursing. Provider #: FBN2858. These materials qualify for 2.0 self-study contact hours.
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Handouts/Brochure
| File type | File name | Number of pages | |
|---|---|---|---|
| Manual - Patient Chart Reviews (4.8 MB) | 36 Pages | Available after Purchase |
Speaker
Rachel Henderson, PhD, MS, RN, HCRM Related seminars and products
Rachel Henderson, PhD, MS, RN, HCRM, is a nationally recognized expert on healthcare law, nursing documentation, and regulatory compliance. With over two decades of experience as a legal nurse consultant, senior leadership roles, and healthcare risk manager, she brings real-world case studies to life in her engaging and informative presentations.
Dr. Henderson is a published author in peer-reviewed journals and textbooks and a sought speaker known for her ability to simplify complex legal and regulatory issues. She is a proud member of the National Speakers Association and a past president of the Florida Speakers Association.
In addition to leading Medical Legal Concepts, LLC, she collaborates with law firms and healthcare organizations, analyzing medical records for compliance with standards of care and applicable regulations. She has served as an expert witness in medical negligence for both plaintiffs and defendants.
Dr. Henderson holds a PhD in Public Policy and Administration, with a focus on Law and Policy. This degree equips her with deep expertise in healthcare regulations, ethics, and legal accountability.
Speaker Disclosures:
Financial: Dr. Rachel Henderson has an employment relationship with Medical Legal Concepts. She receives royalties as a published author and compensation as a legal nurse consultant. 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.
Additional Info
Access for Self-Study (Non-Interactive)Access never expires for this product.
Questions?
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Objectives
- Compare and contrast a medical error and a medical mistake.
- Discuss components of a medical malpractice claim.
- List outcomes associated with proper medical documentation.
- Explain common errors in medical records.
- 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?
- Key elements of a malpractice cause of action lawsuit
- Define Standard of Care
- Acts of omission
- Liability Exposure
- Communicate with other medical personnel
- Minimize exposure to risk management
- Documents, quality measures, and CMS hospital indicators
- Provides proper reimbursement
- Errors in transcription
- Misuse of abbreviations
- Insufficient documentation
- Ignoring crucial information
- Incorrect information entry
- Other medical errors
Target Audience
- Nurses
- Nurse Practitioners
Reviews
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