To provide the registered nurse with clear, concise guidelines to effective documentation.To enhance nursing practice by the creation of an objective medical record that meets mandated regulatory and compliance requirements.To provide the registered nurse with the knowledge to create a medical record that will support oral testimony in a court of law.
Course Publication Date:
September 10, 2021
This course is available with
NO ADDITIONAL FEE if you have an active
one year unlimited membership!
| Author: | Denise L. Gray RN, MAS, BSN, CCM |
| Course No: | LD061521 |
| Contact Hours: | 1.00 |
| Delivery Method: | Online Self Study |
| Category: | Professional Issues
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Learning Objectives
At the conclusion of this course, the registered nurse will be able to:
Identify four purposes of the medical record.
Describe one instance of incorrect documentation.
List how a late entry should be placed in the medical record.
Describe what the terms “objective charting” mean.
Identify the three components that must be included in documenting a patient’s pain.