This course is designed to teach the nurse the importance of proper, timely charting. Demands are ever increasing on nurse and our society has higher expectations than ever before. 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. It is important to note that this course is to provide an overview. Each state, organization, and Board of Nursing may have different rules to follow. If in doubt, always check with your Board of Nursing.
Course Publication Date:
June 17, 2021
This course is available with
NO ADDITIONAL FEE if you have an active
one year unlimited membership!
| Author: | Heather Frommeyer BSN, RN |
| Course No: | END-21 |
| Contact Hours: | 4.00 |
| Delivery Method: | Online Self Study |
| Category: | Pain Management
Substance Abuse
Psychiatric & Mental Health
Professional Issues
Peri-Natal Medicine
Pediatric Medicine
Oncologic Medicine
Career and Self
Medical & Surgical Issues
Leadership & Case Management
Geriatric Medicine
Emergency & Trauma Medicine
Critical Care Medicine
Community & Home Health
Women's Health
Nutrition & Fitness & Complimentary
Perioperative
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Learning Objectives
Identify the significance of maintaining the confidentiality of patient's medical information and records
Identify documentation practices which may be legally unfavorable, including illegible handwriting
Recall the relationship between communication and litigation
Recall specific factors which increase the risk of litigation
Identify integral assessment components of initial and subsequent patient assessments
Identify positive and negative documentation practices
Describe the Joint Commission required components of care which must be evident in the medical record
Identify special documentation circumstances with documentation of pediatric/geriatric/confused patients and those with other communication/cultural barriers
Recognize the significance of the medical record in continuity of patient care