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Nursing Documentation 101

Contact Hours Awarded: 2.5

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Course Overview

Nursing Documentation 101
Morgan Curry

Author: Jillian Hay-Roe

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

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.

Course Objectives

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

Accreditations + 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)
  • New York State Department of Education (IC 208)
  • Florida Board of Nursing (50-23983)

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.

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Course Created on: March 01, 2019

Course Renewed on: February 25, 2022

Course Expires on: February 25, 2025

Course Offering: #3