Texas Hospital Association Foundation
Critical Access Hospital Quality Improvement Program
Frontline Staff Nursing Documentation Workshop
April 22, 2025 – Kerrville, Texas
April 29, 2025 – Abilene, Texas
May 14, 2025 – Canyon, Texas
This program is funded through the Texas State Office of Rural Health
This educational activity is jointly provided by Texas Hospital Association Foundation
and AXIS Medical Education
Critical Access Hospital Quality Improvement Program landing page
Target Audience: This activity has been designed to meet the educational needs of frontline staff in critical access hospitals across Texas. The information is appropriate for all hospital nursing staff.
Overview: Nurses are responsible for thorough and accurate documentation that accurately details the provision of patient care and patient responses to treatments through the course of care. This workshop will provide education on:
- Essential components of nursing documentation
- How EHRs have transformed nursing documentation
- How “checking the box” can create documentation issues
- Legal implications of too little documentation, missing documentation, and documentation errors
- Legal process if a nurse is deposed or called to testify
THAF is committed to providing education and resources to assist hospitals to meet the needs of employees to provide quality, patient-centered care.
Agenda and Learning Objectives
9:00a: Welcome and Introductions
9:30a: Essential components to nursing documentation
Sheila Dolbow, MSN, CPHQ, Quality Improvement Project Manager, Texas Hospital Association
Nina Costilla, MSN, CPHQ, Quality Improvement Project Manager, Texas Hospital Association
- Identify essential components of nurse’s notes
- Describe how essential components make “good documentation”
- Identify ways in which complete documentation improves patient care
10:30a: Break
10:45a: How EHRs have transformed documentation and how “checking the box” can get a nurse in trouble
Sheila Dolbow, MSN, CPHQ, Quality Improvement Project Manager, Texas Hospital Association
Nina Costilla, MSN, CPHQ, Quality Improvement Project Manager, Texas Hospital Association
- Compare and contrast documentation utilizing pen/paper versus utilizing EHR
- Identify ways in which documentation has changed with EHR
- Identify ways in which EHR documentation can create issues
12:00p: Lunch
12:45p: Legal pitfalls of poor documentation
Sheila Dolbow, MSN, CPHQ, Quality Improvement Project Manager, Texas Hospital Association
Nina Costilla, MSN, CPHQ, Quality Improvement Project Manager, Texas Hospital Association
- Describe legal implications for the hospital related to poor documentation
- Describe legal implications for staff related to poor documentation
1:45p: Break
2:00p: So, you are being deposed? (Experiences of a forensic nurse)
Sheila Dolbow, MSN, CPHQ, Quality Improvement Project Manager, Texas Hospital Association
Nina Costilla, MSN, CPHQ, Quality Improvement Project Manager, Texas Hospital Association
- Describe process of a deposition
- Describe courtroom processes
- Identify when and how to engage personal legal council
- Identify strategies to prepare for a deposition or courtroom testimony
3:30: Common documentation errors
Sheila Dolbow, MSN, CPHQ, Quality Improvement Project Manager, Texas Hospital Association
Nina Costilla, MSN, CPHQ, Quality Improvement Project Manager, Texas Hospital Association
- Identify common mistakes with nursing documentation
- Identify strategies to avoid documentation errors
- Describe ways to make appropriate corrections or addendums to patient records
4:30: Wrap Up and Call to Action
4:45: Adjourn
Please contact Sheila Dolbow ([email protected]) if you need more information.
Sheila Dolbow, MSN, CPHQ, Quality Improvement Project Manager, Texas Hospital Association
After becoming a registered nurse in 1993, Sheila began her career in trauma working in a very busy level I emergency department. She advanced her career from bedside care to the development and management of high-level trauma programs where she developed her expertise in quality improvement. During this time, she also practiced as a forensic nurse both in the acute hospital setting and with the local children’s advocacy center. Prior to joining THA, Sheila served as a Health Science educator with the Liberty Hill School District teaching medical courses so that students wishing to pursue healthcare careers could earn dual credit. Sheila joined THA in 2017 to help improve patient safety through the HIIN program. In her current QPS role, Sheila leads the Critical Access Hospital Quality Improvement (CAHQI) project in collaboration with the State Office of Rural Health. In this role she develops and provides education and technical assistance to critical access hospitals across the state. Sheila has also taken on the management of the external peer review portion of the THA Peer Review Network, making assignments for peer review to help hospitals maintain compliance and improve the quality of care provided.
Nina Costilla, MSN, CPHQ, Quality Improvement Project Manager, Texas Hospital Association
Nina obtained both her BSN and MSN from Texas Tech University and began her career as an RN with Texas Health in Dallas. Prior to joining THA she served as an inpatient Nurse Manager for 7 years. Upon joining THA Nina assumed primary responsibility for the HQIC contract deliverables. She also plays a key leadership role with the PSO and contributes to the CAHQI and ASPR programs. Nina’s role and her Green Belt experience allow her to effectively collaborate with quality, patient safety, and risk leaders in THA member hospitals to addresses and improve clinical processes, patient care, and quality outcomes.
ACCREDITED CONTINUING EDUCATION
Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and Texas Hospital Association. AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Credit Designation for Nursing
AXIS Medical Education designates this continuing nursing education activity for 5.75 contact hours.
Learners are advised that accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with an activity.
AXIS Contact Information
For information about the accreditation of this program please contact AXIS at [email protected].