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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.
Emergency Department: HIPAA and CFR42
In an emergency department, information often flows amongst providers and patients quickly because of urgent, sometimes life-threatening, situations. Due to the volume of information being shared, as well as the need for it to be shared quickly and accurately, emergency department providers must be especially careful to safeguard patient information.
The goal of this course is to update nursing professionals in the acute care setting with basic information about the Health Insurance Portability and Accountability Act (HIPAA) and 42 CFR Part 2.
Identify information sharing standards under HIPAA and 42 CFR Part 2.
Define the concept of consent, when you must obtain it to share or receive information, and the types of information that may not be available to you.
Essentials of HIPAA
This course, which was designed to comply with HIPAA law, will help you protect the privacy of the people you provide care for. Allowing unauthorized individuals to see a person’s personal health information can have severe consequences for you and your organization, even if it happens by accident.
The goal of this course is to provide post-acute care staff with basic information about the principles of confidentiality, privacy, and security.
Explain why HIPAA exists.
Identify at least three things in the medical record that can be used to identify an individual.
Describe at least three best practices to prevent HIPAA violations.
HIPAA: Basics
The Health Insurance Portability and Accountability Act, commonly called HIPAA, protects the confidentiality and security of healthcare information. HIPAA creates and protects individual privacy rights for protected health information and governs the use and disclosure of that information.
The goal of this course is to provide all staff with an overview of the principles of HIPAA.
The content of this course is sourced from 45 CFR Parts 160,162, and 164 (2020) or HIPAA-related resources from the Health and Human Services (HHS) unless otherwise noted.
Define the purpose of HIPAA.
Recognize when a HIPAA violation has occurred.
Identify three steps you can take to avoid a HIPAA violation.
HIPAA: Do's and Don'ts of Social Media and Electronic Communication
Social media and other forms of electronic communication allow people to instantly share pictures and messages with anyone, anywhere. But as the opportunities to share information online have increased, so have the challenges for keeping information private.
The Health Insurance Portability and Accountability Act, known as HIPAA, was designed to protect individuals’ rights and their personal healthcare information. HIPAA applies to both the storage and transfer of electronic protected health information, so these electronic communications must be handled carefully.
Describe at least three ways to avoid HIPAA violations when using electronic communication.
HIPAA: Privacy Rule
All healthcare organizations must follow a specific HIPAA rule, known as the Privacy Rule. This rule limits the use and disclosure of protected health information, known as PHI. The Privacy Rule also grants people the right to view and correct their medical records, receive copies, or request that copies are sent. The goal of this course is to provide all staff with knowledge of the HIPAA Privacy Rule.
Recognize common violations of the HIPAA Privacy Rule.
Identify ways to prevent violations of the HIPAA Privacy Rule.
HIPAA: Security Rule
The use of technology has bloomed in the healthcare industry. While technology’s use has improved the delivery and continuity of care, it increases the chance that an unauthorized person will be able to access individuals’ protected health information, or PHI. Therefore, to protect electronic PHI, your organization is required to follow a specific HIPAA rule, known as the Security Rule.
The goal of this course is to describe the Security Rule and ways you can prevent breaches.
Describe the HIPAA Security Rule.
Identify at least three ways to prevent breaches of the HIPAA Security Rule.
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.