Nursing Documentation 101

Course Overview

Course Outline

1. Introduction
2. The Who, What, When, Where and How of Documentation
3. Technology and Medical Records
4. Documentation and Artificial Intelligence (AI)
5. Protected Health Information / Privacy and Security
6. Retaining Medical Records
7. Medical Records Disposal
8. Medical Records and Crime
9. Client Rights to Protected Health Information
10. Documentation Content Requirements
11. When Documentation Becomes Your Defense
12. Costs
13. What is Required for Nursing Documentation?
14. Examples of Good and Bad Nursing Documentation
15. Common Documentation Errors
16. Conclusion

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.

In this course we will learn how to properly document patient care. It will take the average learner 150 minutes to complete and awards 2.5 contact hours upon completion

Course Objectives

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

1. List important components to include and avoid in a client’s medical record. 
2. Describe how to apply good documentation principles to clinical practice. 
3. Summarize legal considerations for medical records. 

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

Accreditations + Approvals

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.