ANCC Approved - Effective Nursing Documentation

Subject areas

This course counts toward the state boards and subject areas below.

Disclosure statements

Learning Objectives

At the conclusion of this course, participants will be able to:

1. Identify the significance of maintaining the confidentiality of patient's medical information and records
2. Identify documentation practices which may be legally unfavorable, including illegible handwriting
3. Recall the relationship between communication and litigation
4. Recall specific factors which increase the risk of litigation
5. Identify integral assessment components of initial and subsequent patient assessments
6. Identify positive and negative documentation practices
7. Describe the Joint Commission required components of care which must be evident in the medical record
8. Identify special documentation circumstances with documentation of pediatric/geriatric/confused patients and those with other communication/cultural barriers
9. Recognize the significance of the medical record in continuity of patient care

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• This course reports to CE Broker immediately upon completion.
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