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Home Care Documentation and Legal Issues

In this class you will learn how to properly document a home care visit. Topics include

  • Documentation standards (State and Federal laws, RN Scope and Standards of Practice, Nurse Practice Act, Joint Commission, Medicare/Medicaid, professional organizations)
  • Basic principles of documentation
  • Computerized and hand-written documentation
  • Documentation Do's and Don'ts
  • Legal implications and how to limit your liability
  • One (1) contact hours will be awarded to all participants
  • Special large group class arrangements on request

Objectives: Upon completion of the presentation the participant will be able to

  1. Identify the importance of understanding the current standards of practice and your state's Nurse Practice Act.
  2. Explain the importance of safe and complete documentation.
  3. Identify basic information that is required when documenting in the medical record and tips for improving documentation.
  4. Identify documentation errors to avoid.
  5. Define negligence.
  6. Identify skills that will reduce your liability risk.

If no session dates are listed please contact PHS to schedule a class date. 

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