Nursing Documentation: Quality, Technology, and Privacy

Course overview

Nurse documentation should be high quality, but what exactly does that mean? This course reviews the concepts of high-quality documentation and how that relates to technology and patient privacy. Most documentation takes place within electronic health records (EHRs) and nurses must understand how to practice high-quality documentation using these electronic methods. There are challenges with technology, but also lots of exciting developments that can improve nurse documentation. Technology also comes with concerns for breaches of confidentiality; nurses must know how to safeguard their nurse documentation and the EHR from unauthorized use. The goal of this course is to update nurses in the acute care setting on best practices for high-quality documentation, maintaining patient privacy, and using technology to make the most of nursing documentation.