Basic Guidelines for Nursing Documentation
The goal of this course is to help nurses learn the basic guidelines for proper documentation of medical records.

Course Publication Date: April 19, 2018

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

Author:Anita Rothera-Delaney RN, BS
Course No:ND041218
Contact Hours:1.00
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
  • 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.
  • 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.


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