Medical Record Documentation

At the end of this course the learner will be able to:

1. List 4 things that are required to provide proper documentation.
2. Provide 3 reasons why documentation is important.
3. Describe 2 situations of how your documentation can help a resident.
4. Provide 3 examples of changes in a resident's condition that should be immediately reported as well as documented.
5. Describe what can happen if documentation is not properly done.
6. Describe the actions you should take when a resident refuses care.