Li-041302 3 East Documentation Skills Validation
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Type
Live
Credit
No
Description
Introduces staff to the principles and practices of effective clinical documentation. Focuses on accuracy ... show more
Objectives
- Demonstrate accurate and timely documentation of patient assessments, interventions, and outcomes in accordance with organizational policies and regulatory standards. Apply critical thinking skills to determine what information is essential to document for patient safety and continuity of care. Differentiate between objective and subjective data and record findings using professional, concise, and legally sound language. Identify common documentation errors and risks (e.g., omissions, vague language, late entries) and apply strategies to prevent them. Utilize electronic health record (EHR) systems effectively to ensure legibility, accuracy, and compliance with charting requirements. Maintain patient confidentiality and privacy when documenting and communicating care, following HIPAA and organizational guidelines. Validate competency through simulation and/or hands-on practice, demonstrating proper charting of assessments, interventions, and responses.
Fees
Free
Activity Director
Pamela Shareef
Organization
MedStar Southern Maryland Hospital Center