Documentation Basics
The goal of this module is to provide the reader with an enhanced understanding of the significance of nursing documentation. Tips to enhance charting quality and improve legibility will be presented.

Course Publication Date: September 18, 2015

This course is available with NO ADDITIONAL FEE if you have an active one year unlimited membership!

Author:Susanne J. Pavlovich-Danis RN, MSN, ARNP-C, CDE
Course No:DB082615
Contact Hours:4.00
Delivery Method:Online Self Study
Category:Career and Self
Community & Home Health
Critical Care Medicine
Emergency & Trauma Medicine
Geriatric Medicine
Leadership & Case Management
Medical & Surgical Issues
Nutrition & Fitness & Complimentary
Oncologic Medicine
Pain Management
Pediatric Medicine
Peri-Natal Medicine
Professional Issues
Psychiatric & Mental Health
Substance Abuse
Women's Health

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Learning Objectives
  • Identify the significance of maintaining the confidentiality of patient's medical information and records
  • Identify charting practices which may be legally unfavorable, including illegible handwriting
  • Discuss the relationship between communication and litigation
  • List specific factors which increase the risk of litigation
  • Identify integral assessment components of initial and subsequent patient assessments
  • Identify positive and negative charting practices
  • Describe the Joint Commission required components of care which must be evident in the medical record
  • Identify special charting circumstances with documentation of pediatric/geriatric/confused patients and those with other communication/cultural barriers
  • Discuss the significance of the medical record in continuity of patient care


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