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

Course Publication Date: May 28, 2020

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:END052820
Contact Hours:1.00
Delivery Method:Online Self Study
Category:Substance Abuse
Psychiatric & Mental Health
Professional Issues
Peri-Natal Medicine
Pediatric Medicine
Pain Management
Oncologic Medicine
Leadership & Case Management
Medical & Surgical Issues
Geriatric Medicine
Emergency & Trauma Medicine
Critical Care Medicine
Community & Home Health
Career and Self
Nutrition & Fitness & Complimentary
Women's Health
Learning Objectives
  • 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.

  • 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.

  • Name three ways to avoid nursing liability for inadequate or inaccurate documentation.


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