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Documentation: The Legal Side
As a professional nurse, you are expected to be familiar with many aspects of care. You are not exempt from malpractice or negligence claims because you were following orders. You are responsible for assessing, planning, implementing, and evaluating appropriate nursing care. What you document can and does reflect the care provided and the outcomes of that care. Documentation that is factual, complete, timely, and detailed is required. In this course, you will learn about concepts and rules regarding documentation in the medical record. Legal aspects to be aware of while practicing will also be discussed. The goal of this course is to educate nursing professionals in post-acute care settings about the legal implications of documentation.
Discuss malpractice, negligence, and compensatory and punitive damages as they relate to healthcare. Explain four intentional torts that a healthcare professional may be held liable for. Describe four documentation techniques to use to avoid legal issues.
HCAHPS: Patient Care Experience
Hospitals and providers currently receive reimbursement by meeting criteria established by the Centers for Medicare & Medicaid Services (CMS). Quality measures and length of stay data are measures that affect hospital reimbursement. Yet the patient’s experience of care also remains a key factor in hospital reimbursement models. CMS uses the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to measure the patient’s experience, and nursing care is one part of the survey. Hospitals that perform well on the HCAHPS ratings are more likely to receive better reimbursement and bonuses. Nurses impact hospital ratings and reimbursement by providing the patient with a positive care experience.
Describe the impact of patients’ perception of their care experience on hospital reimbursement.
Discuss HCAHPS survey questions about staff responsiveness and strategies for improving survey ratings for these items.
Discuss the HCAHPS survey questions about medications and strategies for improving survey ratings for these items.
HCAHPS: Transitions of Care and Discharge
Improving hospital processes surrounding discharge and transitions of care can reduce adverse events and readmissions. Process improvements may also lead to better patient adherence to the treatment plan and their overall experience with care. Healthcare professionals must understand care coordination and transitions of care and how they impact HCAHPS survey results.
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a national standardized survey required for hospitals participating in Centers for Medicare & Medicaid Services (CMS) programs. Survey results are linked to hospital reimbursement from CMS.
Identify the impacts of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Hospital Value-Based Purchasing (HVBP) programs on healthcare organizations.
Categorize transitions of care, care coordination, and discharge planning.
Select strategies to improve interprofessional teamwork.
Implementing Shared Governance: Excellence Series
This course focuses on the role that shared governance plays in the nursing profession. Participants will learn what shared governance is and how it can benefit nurses. They will also learn how to implement shared governance programs and enhance programs that already exist. Learners will explore strategies to enhance decision-making processes, promote nursing engagement, and improve patient outcomes through shared governance.
Indicate the foundational principles of a shared governance system.
Recognize strategies for implementing shared governance and overcoming barriers to participation.
Recall the advantages of a shared governance system.
Medical Record Documentation and Legal Information for CNAs
Documenting care is just as important as providing care. This course discusses the purpose of the medical record and documentation. It also describes documentation practices and legal standards that affect the certified nursing assistant.
This course provides direct care workers in post-acute care education on documentation and legal aspects of care.
Discuss the purpose of the medical record and documentation.
Identify at least two documentation practices used to avoid errors.
Explain the legal standards that affect the certified nursing assistant.
Minimizing Trips, Slips, and Falls
This course is about workplace slip, trip, and fall hazards. It alerts you to the serious consequences that can result even from a simple fall or a near fall and provides information about measures that can help you prevent these incidents and reduce potential injuries.
Identify common hazards that might lead to trips, slips, and falls.
Explain how to prevent injuries from trips, slips, and falls.
Preventing and Handling Crisis Situations
Healthcare professionals often encounter patients experiencing agitation or displaying hostile behavior during their careers. De-escalation is a set of approaches and techniques used to assist patients in self-calming to avoid incidents of harm to self, others, or property. Professionals should understand escalation and physiological responses to threats. After determining the risk of escalation, healthcare professionals can use various aspects of verbal communication, such as tone and pitch, and nonverbal communication skills to defuse potentially hostile situations and apply the least restrictive interventions.
Describe what de-escalation is and why it is important.
Recall how to use de-escalation to prevent a crisis from developing.
Indicate specific approaches you can use during a crisis to help individuals return to pre-crisis levels of functioning and prevent harm.
Prevention of Adverse Events and Medical Errors
The prevalence of medical errors correlates with increased risk of patient harm in the healthcare setting. Since most errors are related to systems issues/failures and not to inadequate care by providers, it is critical to understand the breadth of the problem and the best ways to prevent adverse events and medical errors to improve patient safety.
Examine the relationship between adverse events, medical errors, and patient safety.
Identify the barriers to improving patient safety through reducing errors.
Principles of Risk Management
Risk managers, administrators, and managers should be aware that there are always risks involved with business operations. Consequently, they must have solid risk management practices and programs to help identify, assess, and manage risks of all sorts. Risk management practices should be integrated across major organizational departments, initiatives, and programs, such as service delivery, safety, security, business and public communications, and supply chain, to name a few.
The goal of this course is to provide administrator professionals with an overview of risk management principles.
Define risk management.
Identify at least four concepts related to risk management.
Name at least two risk response strategies used in risk management programs.
Quality Series: Safety First - Culture and Patient Impact
A ‘culture of safety’ is an often-heard term in clinical settings. Most patients require complex care, with many interprofessional teams working together. Large patient volumes, an expectation for rapid delivery of care, the consumer’s ability to choose providers, and government reimbursements all drive acute care facilities to invest in preventing or reducing errors. Improving safety is beneficial to the patient primarily, with less risk of injury or death, but also to the facility and staff, improving retention and job satisfaction, with the added benefit of extensive cost-savings.
Describe the identifying factors and benefits to a culture of safety.
Discuss organizations responsible for driving patient safety changes on a national level.
Evaluate barriers to patient safety, and how these can be reduced or eliminated.
Responding to Employee Incidents
The Bureau of Labor Statistics (BLS) reported that in 2019, 5,333 work-related injuries resulted in death. These numbers show a 2% increase over 2018 figures and represent the most significant one-year increase since 2007 (BLS, 2020a). This course discusses the story behind the statistics. The key to reducing incidents and injuries in your organization is to prevent incidents from happening. To prevent incidents, you must understand what causes them. This course will help you to understand the significant role you play in incident investigation and prevention.
Describe the importance of workplace safety.
Explain the process in investigating an incident.
Identify the importance of timely, accurate, and through incident investigations.