The purpose of this program is to familiarize the attendee with the 2011 Joint Commission chapter on Record of Care. This chapter summarizes what needs to be documented in the medical record. Hospitals should review this chapter when updating their assessment forms to ensure compliance. This chapter is extremely important as hospitals medical records become electronic to ensure that the required standard is captured as a field in the electronic record.  

In this 90-minute interactive webinar, nurse attorney Sue Dill Calloway will cover why hospitals must review this chapter when updating their assessment forms to ensure compliance especially because medical records are going electronic. Come learn how to comply with this challenging standard.

Learning Objectives:

• Discuss the importance of the TJC standards in electronic charting.  
• Describe the TJC documentation requirements for verbal orders and history & physicals.  
• Discuss how TJC required elements should be incorporated into hospital forms and documents.
• Describe the requirement that hospitals must audit its medical records.
• Discuss why the medical record must contain a summary list for each patient receiving continuing ambulatory care services.
• List what needs to be documented if restraint or seclusion is used.
• Discuss the 2011 changes on improving patient-provider communication.

Target Audience:

• Physicians
• Nurses 
• Risk managers
• Hospital attorneys
• Chief operating officer
• Chief nursing officer
• Compliance officers
• Joint Commission coordinators and quality and performance improvement staff
• Policy and procedure committee members
• Case managers
• Health information management director and staff
• Documentation specialist
• Computer programmers
• Nurse educators
• Nurse managers
• Patient safety officer
• Audit committee

Level: All levels 

Meet your Expert:

Sue Dill Calloway is a nurse attorney and medical-legal consultant. She has done many educational programs for nurses, physicians, and other health care providers. She has spoken internationally on patient safety, risk management, legal, regulatory, and CMS and Joint Commission issues. She has authored over a thousand articles and a hundred books including a book on the Compliance Guide to the Joint Commission, CMS Patient Rights Standards and a book on 2009 Joint Commission Leadership and many books on nursing law and nursing law and ethics.  

Her associate degree is from Central Ohio Technical College and Ohio State University. Her BA, BSN in Nursing, MSN in nursing (summa cum laude) and JD degree (law degree with honors) are from Capital University in Columbus, Ohio.

Accreditation Statement:

AHC Media is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Credit Designation:

This activity has been approved for 1.5 nursing contact hours using a 60-minute contact hour.

Provider approved by the California Board of Registered Nursing, Provider # 14749, for 1.5 Contact Hours.

Sponsor:

The sponsor of this educational activity is AHC Media.

Recorded: Tuesday, November 29, 2011