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Documentation Update 2020 Update; Ensuring Compliance

Recorded Session | Sue Dill Calloway | From: Sep 15, 2020 - To: Dec 31, 2020
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Course Description

This webinar is a must-attend program for any nurse, physician, or healthcare professional working in healthcare today. It will discuss the importance of documentation to avoid allegations of malpractice, substandard care, accreditation nightmares, and denial of reimbursement. Good concise documentation is the key to preventing claims of fraud and abuse. It is also important if the medical records are reviewed by the Recovery Audit Contractors (RACs), the Office of Inspector General (OIG), or CMS.

This program will help improve documentation skills. It will discuss legal issues in documentation, and the Joint Commission and CMS hospital CoP issues related to documentation requirements. It will provide over 50 recommendations to improve documentation. Many hospitals have seen an increase in documentation problems with the introduction of the electronic health record.

It will cover key problematic Joint Commission and CMS Hospital CoP requirements including some requirements effective November 29, 2019. It will cover what is required to be documented by the Joint Commission record of care chapter. It will help identify issues that need to be documented in order to be reimbursed by CMS and to avoid allegations of fraud and abuse and improper documentation by the RACs (recovery audit contractors).  Is medical necessity documented in light of the two-midnight rule? It will include the requirement for the MOON form for outpatient observation patients and there is a new form in 2020. CMS now requires all patients who stay overnight to have an order that the patient is either an inpatient or placed in an outpatient observation bed.

It will cover the importance of documenting the presence of things like pressure ulcers which are one of the 14 hospital-acquired conditions (HACs) in which there will be no additional payment so hospitals could lose money if this is present on admission and not documented. This program will also assist in determining the fields that should be present as hospitals tweak or amend electronic medical records to capture the elements required by CMS and the Joint Commission.

This program will also include some things hospitals should do and document to prevent unnecessary readmissions. Hospitals will a higher than average rate of readmission are being financially penalized by CMS. This program will discuss how to document to comply with the CMS regulation on visitation including documentation if the patient wants their physician or family notified. This program will help hospitals as they move toward an electronic medical record to discuss some of the CMS and TJC documentation requirements that should be entered as a field. This program will cover the CMS requirements for protocols, standing orders, and order sets and how to document these into the medical record.

Legal Issues in Documentation:-

  • Introduction
  • Charting bloopers
  • Admissibility of medical records
  • MOON form for outpatient observation patients
  • Document either admission or outpatient status
  • Fading memories
  • Use of checklists
  • 50 tips to improve documentation based on case law
  • Why document
  • Record date/time
  • Legibility and doctors signature must be legible on all orders
  • Recording name of the caregiver
  • Charting all nursing actions
  • Safeguards to protect  patient
  • Objective documentation
  • RAC and documentation issues
  • 2-midnight rule and certification and medical necessity
  • Joint Commission Record of Care Chapter requirements
  • Spelling
  • Late entries
  • Amendments
  • HIPAA amendment requirements
  • CMS preprinted orders
  • CMS standing orders
  • Documenting for others
  • Countersigning
  • CMS and TJC Informed Consent
  • Medication management documentation
  • Signing your chart properly
  • Abbreviations
  • Code charting
  • Joint Commission new  documentation chapter
  • CMS and TJC Verbal order documentation
  • Notification of family or physician
  • CMS informed consent
  • Avoid vague expressions
  • Documenting telephone orders
  • Patient non-compliance
  • Observation patients
  • Omitted or late entries
  • Complete medication information
  • Incident reports
  • Interpreters including OCR 1557 requirements
    • Sign
    • Amended patient rights
    • Qualified interpreters
  • Pain assessments
  • TJC pain standards
  • PCA and documentation of information
  • Patient education documentation
  • Discharge instructions and preventing readmission
  • Document chain of command
  • Document OR checklist
  • Time Outs
  • Plan of care (TJC and CMS problematic standard)  
  • Skin assessment/skin tears
  • Circulation checks
  • Fall assessment
  • IV documentation
  • Admission assessments
  • Code charting
  • NPO status and I&O
  • Abnormal X-ray and lab results
  • Advance directives
  • Documenting to comply with CMS Visitation standard


  • Discuss two recommendations or tips to improve documentation to reduce the risk of liability.
  • Explain the importance and what should be documented in the assessment of pain.
  • Describe what TJC has the Record of Care chapter which includes many things that must be documented in the medical record.
  • Explain the CMS requirement that all orders be in writing in the order sheet even if hospitals use approved protocols.
  • Discuss that both CMS and Joint Commission have standards that require specific documentation of  verbal orders

Who Will Benefit?

Chief Executive Officer (CEO), Chief Operating Officer (COO) Chief Nursing Officer (CNO), Nurse Managers, All Nurses, Nursing Supervisors, Compliance Officer, Joint Commission Coordinator, Quality Improvement Coordinator, Clinic Directors,  Consumer Advocates, RAC coordinator, compliance officer, director of regulatory affairs, physicians, Risk Managers, Patient Safety Officer, Staff Nurses, Nurse Educators, Department Directors, Chief Medical Officer (CMO), physicians, Legal Counsel, Documentation Specialist, Health Information Management Director, and staff, department directors, PI director, and staff and anyone involved in the documentation process.