The goal of this course is to help healthcare professionals learn the basic guidelines for proper documentation of medical records.
Course Publication Date: April 14, 2016
This course is available with NO ADDITIONAL FEE
if you have an active one year unlimited membership
|Author:||Anita Rothera RN, BS
|Delivery Method:||Online Self Study
|Category:||Career and Self
Community & Home Health
Critical Care Medicine
Emergency & Trauma Medicine
Leadership & Case Management
Medical & Surgical Issues
Nutrition & Fitness & Complimentary
Psychiatric & Mental Health
- Discuss National Patient Safety Goals for Hospitals from JCAHO.
- Name five sections of information a medical record must contain.
- Discuss why computerized charting is good.
- Name three ways to avoid nursing liability for inadequate or inaccurate documentation.
- Describe major issues involved in documentation litigation.
- Discuss how documentation on the patient’s medical record is controlled.
- Discuss how care plans provide a structured approach to the assessment, planning and delivery of patient care.
- Describe the challenge of institutions to help nursing staff refine their charting skills.