Return to HealthCap Home Page

Documentation Lessons Learned

Recorded On: 12/27/2024

Hindsight is 20/20, you have heard that phrase in the past! When it comes to resident care, hindsight is 0/0! Identifying subtle changes in condition through observation and assessment may assist in decreasing the risk of negative outcomes. This approach includes a thorough assessment process, care plan development, supervision, and identifying subtle changes in condition to assist in decreasing the risk of negative outcomes. This program was developed to assist you in identifying ways to improve documentation that meets best practices because hindsight is not 20/20! 

 Objectives:

  • Describe why good documentation is important 
  •  Identify examples of poor documentation
  •  Identify issues with inaccurate documentation

Jill Harding, RN, LNHA, CLNC

Risk Manager

HealthCap

Jill Harding has served our long-term care industry for over two decades in various roles throughout skilled nursing facilities. She has been a Registered Nurse since 2011 and a Licensed Nursing Home Administrator since 2014 having served in both For-Profit and County Owned Medical Care Facility.

As a Certified Legal Nurse Consultant (CLNC), she serves her passion from both sides of our industry from a regulatory and healthcare legal perspective to help provide the best outcomes. She specializes in medical malpractice defense cases, utilizing decades of first hand clinical, administrative and regulatory experience.

In addition to her CLNC services, Jill serves her love of continuing to work alongside our healthcare facilities as a Risk Management/Loss Control Consultant and Healthcare Consultant & Educator. Providing support and education to homes in areas of operations, regulatory compliance and risk management services.

Key:

Complete
Failed
Available
Locked
Video
Open to view video.  |  32 minutes
Open to view video.  |  32 minutes
You must register to access.
Quiz
5 Questions  |  Unlimited attempts  |  4/5 points to pass
5 Questions  |  Unlimited attempts  |  4/5 points to pass If a resident shows verbal frustration about taking medications, discussing the specific medication with the physician could help determine if it is critical for the resident's day-to-day quality of life or if it can be discontinued.
You must register to access.
Webinar Evaluation
8 Questions
8 Questions Complete an evaluation of your learning and professional development to earn your certificate.
You must register to access.
Certificate
No credits available  |  Certificate available
No credits available  |  Certificate available
You must register to access.