Effective Nursing Documentation
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 MSN Ed, 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
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


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