Documentation Update 2019: Ensuring Compliance

Event Information
Product Format
Live Webinar
Sue Dill Calloway, RN, MSN, JD
Conference Date
Add to my calendar   Tue, Mar 19, 2019
Aired Time
1 pm ET | 12 pm CT | 11 am MT | 10 am PT
120 minutes
Product Description

Learn 50-Plus Tips to Improve Your Documentation in 2019

Properly documenting your patients’ records has never been more important than it is now in the current healthcare landscape—where your reimbursement is tied to the quality of your medical records. It helps avoid allegations of malpractice, substandard care, accreditation nightmares and denial of reimbursement—and above all—comply with the recent changes in CMS standards.

Catch up on the recent documentation updates in this webinar by healthcare expert Sue Dill Calloway. Calloway will bring you up to speed with the legal issues in documentation, and provide 50-plus recommendations to improve your documentation in 2019. She will walk you through key problematic Joint Commission and CMS Hospital CoP requirements, including what is required to be documented by the Joint Commission record of care chapter. This will not only ensure that you receive proper reimbursement from CMS, but also help avoid allegation of fraud, abuse, and improper documentation by the recovery audit contractors (RACs).

Calloway will explain the importance of documenting pressure ulcers (and how not to lose money on it); assist you in determining the fields that should be present as hospitals move toward electronic medical records to capture the elements required by CMS and the Joint Commission. You will also learn how to prevent unnecessary readmissions and therefore avoid being penalized by CMS; how to comply with the CMS regulation on visitation (including documentation) if a patient wants their physician or family notified; and about MOON form requirement for outpatient observation patients.

After attending this session, you will have a firm grasp of the proposed changes to the CMS manual—and you will be equipped to avoid the all-too-common pitfall of inadequately documenting outpatient care. You will fully understand CMS’s requirements for documenting protocols, standing orders, and order sets in the medical record.

Session Highlights

This session will:

  • Discuss 2 recommendations/tips to improve documentation and reduce the risk of liability
  • Explain what should be documented in the assessment of pain (and its importance)
  • Describe the requirements set forth in the Record of Care chapter, which includes many things that must be documented in the medical record
  • Explain 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 Should Attend

  • CEO and COOs
  • Chief nursing officers (CNO), nurse managers, and supervisors
  • Compliance officers, joint commission coordinators, quality improvement coordinators
  • Clinic directors
  • Consumer advocates, RAC coordinators, director of regulatory affairs
  • Physicians, risk managers, patient safety officers,
  • Nurse educators
  • Department directors, chief medical officers (CMO)
  • Legal counsel
  • Documentation specialists

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

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About Our Speaker

Sue Dill Calloway - Hospital Coding Expert

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the...   More Info
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