As our industry evolves, we have a powerful opportunity to foster a culture that empowers our team to practice safe, defensible documentation. With regulatory standards and legal liability increasing, we’ll examine real cases where documentation practices placed healthcare professionals at risk and how valuable our leadership is in reducing these risks exposures. Together, we’ll focus on how to support our teams through aligned practices and proactive oversight that supports a culture that elevates our resident’s care, safeguards our staff, and strengthens our entire organization.

Nurse Learner Outcome:

Learner Objectives:

1. Identify defensible documentation needed to support and lead their nurses to document accurately, objectively and in compliance with regulatory and legal standards.
2. Explain the risk that can lead to potential criminal charges against healthcare professionals.
3. Examine how nursing leaders can help implement proactive, defensible documentation practices and oversight systems to help prevent these potential situations from occurring.
4. Describe the importance of auditing documentation as a strategy to strengthen quality of care, ensure regulatory compliance, and proactively identify and mitigate potential risks exposures.