Accurate and Legal Documentation

Course overview

Purpose The purpose of this course is to outline accuracy and legal requirements for nursing documentation, including a review of different formats for documentation. Explain the purposes for documentation. Explain the differences among the NANDA nursing diagnoses, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC). Discuss the Health Insurance Portability and Accountability Act, Privacy Rule. List and explain at least 8 different factors to consider in documentation. Explain how to document errors, continuations, and late entries. List and explain the primary characteristics of different formats for documentation. Explain how critical pathways are used. Discuss 3 common components of computerized documentation systems. Introduction Documentation is a form of communication that provides information about the healthcare client and confirms that care was provided. Accurate, objective, and complete documentation of client care is required by both accreditation and reimbursement agencies, including federal and state governments.