Nursing Documentation 101
Contact Hours: 2.5
What's included?
Course Overview
This course is designed to give learners an overview of the best documentation practices for anyone in healthcare who contributes to a client’s medical record. Primarily, this course is geared toward the most common healthcare workers in the medical profession: nurses. This extends from nursing assistants and licensed practical/vocational nurses to registered nurses and advanced practice registered nurses. The course will cover the reasons why documentation is important to client care, but also to protect the healthcare worker’s license. It will give examples of how assessments, procedures, and actions should be documented, as well as what should be avoided.
Course Outline
- Introduction
- The Who, What, When, Where, Why, and How of Documentation
- Technology and Medical Records
- Downsides of the Electronic Medical Record (EMR)
- Retaining Medical Records
- Medical Records Disposal
- Medical Records and Crime
- Client Rights to Protected Health Information
- Documentation Content Requirements
- When Documentation Becomes Your Defense
- Costs
- What is Required for Nursing Documentation?
- Examples of Good and Bad Nursing Documentation
- Common Documentation Errors
- Conclusion
Course Outcomes
After completing this course, the learner will be able to:
- List important components to include and avoid in a client’s medical record.
- Describe how to apply good documentation principles to clinical practice.
- Summarize legal considerations for medical records.
Accreditations and Approvals
- American Nurses Credentialing Center (ANCC) (P0614)
- California Board of Registered Nursing (CEP 17418)
- Kentucky Board of Nursing (7-0090)
- Louisiana State Board of Nursing (58)
- Florida Board of Nursing (50-23983)
- Delaware Board of Nursing (DE-24-010127)
- Alabama Board of Nursing (#ABNP1577)
- Iowa Board of Nursing (#393)
- Kansas Board of Nursing (LT0340-0325)
Approved by the Board of Nursing in every state, you can complete your RN, LVN, and APRN CEUs with confidence.
Accreditation Statement
Nursing CE Central LLC is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation.
It will take the average learner 150 minutes to complete and awards 2.5 contact hours of continuing education.
Written For
- Registered Nurses (RN)
- Advanced Practice Registered Nurses (APRN)
- Licensed Practical Nurses (LPN/LVN)
Requirements for Completion
- Enrollment in the course by the learner
- Read and learn all course materials
- Complete the course evaluation
- Attest and testify learning of the course materials
Disclosure of Relevant Financial Relationships
Nursing CE Central nor any of the authors, planners, content experts, or any contributors have any relevant financial relationships with ineligible companies to disclose.
