Documentation Update:  Vital Components for Compliance
Tuesday, August 17, 2021
9:00 am - 10:30 am CST

Offered Through Partnership with Georgia Hospital Association

Documentation remains one of the more problematic components of healthcare.  While it is crucial for provision of safe care and communication across the healthcare continuum, proper documentation is also a major element in compliance and reimbursement from the Centers for Medicare & Medicaid Services (CMS) and third-party payors.  Inadequate, incorrect, and missing documentation can lead to failure to diagnose, missed diagnosis, lapse in vital care and citations from regulatory agencies.

This program will cover the basics of documentation, as well as principles set out by the American Nurses Association (ANA), expectations from CMS and the Joint Commission. Additionally, legal implications surrounding documentation will be addressed.

The Interoperability and Open Records act, that went into effect April 2021, will also be reviewed.  The impact of the Act and the completion of documentation will be discussed. In addition, the conditions of participation, as they relate to documentation of patient care, including restraints and seclusion, medication administration, and discharge planning will be covered. 

Finally, case studies will be included to show how content, or lack thereof, in documentation resulted in either a decision for the healthcare provider or the plaintiff.

Learning Objectives:
At the conclusion of this session, participants should be able to:

• Recall the American Nurses Association’s principles for nursing documentation.
• Describe the regulatory and professional requirements and expectations for documentation.
• Recite the basic requirements for interoperability and Open Records.
• Explain the importance of documentation in preventing and/or defending medical malpractice cases.

Laura A. Dixon is the president of Healthcare Risk Education and Consulting. She previously served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020.  In her role, Ms. Dixon provided consultation and training to facilities, practitioners and staff in multiple states. 

Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services and pain management.  Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California.  In this capacity, she provided consultation to the physicians and staff for the western United States.  

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, a Doctor of Jurisprudence degree from Drake University College of Law, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing.  She is licensed to practice law in Colorado and California.