Documentation image
04
Mar

Contact Hours Awarded: 2.5

Documenting is at best a useful tool for communication and at worst a necessary evil. It is well-known that documenting is one of the most tedious aspects of bedside nursing. It takes time away from patient care and may be used for (or against) you in court. In this CE module we will learn how to document properly. Proper documentation is an essential for defense against claims and continuity/quality of care in nursing.

Course outline:

  1. Introduction
  2. The Who, What, When, Where, Why and How
  3. Privacy and Security
  4. The Legal Requirements
  5. When Documentation Becomes Your Defense
  6. The Cost
  7. What is Required for Nursing Documentation?
  8. Examples of Good and Bad Charting
  9. Common Documentation Errors
  10. Conclusion
  11. References (Bibliography)

Accreditation statement: Nursing CE Central is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

More course information

In this course we will learn how to properly document patient care. It will take the average learner 125 minutes to complete.

After completing this course, the learner will be able to:

1.) Describe best practices regarding documentation.

2.) Identify examples of proper and improper charting in everyday practice.

3.) Understand the importance of proper documentation.

Target audience: 

Registered Nurses (RN)

Advanced Practice Registered Nurses (APRN)

Licensed Practical Nurses (LPN/LVN)

Requirement for completion:

1.) Enrollment in the course by the learner

2.) Read and learn all course materials

3.) Complete the course evaluation

4.) Attest and testify learning of the course materials

Course offering: # 3

Accreditations and approvals:

ANCC (Provider# P0614)
California BRN (Provider# 17418)
Kentucky Board of Nursing (Provider# 7-0090)

Course expiration date: March 1, 2022

Conflict of interest statement: Nursing CE Central nor any of the authors, planners, content experts or any contributors have a commercial interest nor were influenced by commercial interests in the creation of this course, financially or otherwise.

Course Content

Total learning: 1 lesson Time: 15 days
  • Nursing Documentation 101: How to Guard Your License  0/1

Instructor

Jillian Hay-Roe, RN, BSN, RN-NIC, LNC

Jillian is a Registered Nurse and Legal Nurse Consultant. She obtained her Legal Nurse Consulting Certificate from the University of Florida and currently practices in sunny Phoenix, Arizona. She is also a clinical nursing instructor for Carrington college.

Free

In this course we will learn how to properly document patient care.