Documentation: Basic Principles

Price (includes one year of access and CE):  US$12
Course Code: 7SENNF-PRV-09-libdoc
CE: 2.00 Hours.
Post Test Score Required for Successful Completion: 80%
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Course Overview:

Complete, objective, and accurate documentation of nursing care has taken many forms over the years, moving from narrative notes, flow sheets, and check lists, to today's high-tech computerized patient record. Every healthcare facility has its own policies and procedures related to documentation and may use several of these forms within one facility. As nursing documentation evolves to meet the requirements of our society's changing healthcare paradigm, understanding the basic principles of documentation remains critical. This program describes the importance of documentation in safeguarding and optimizing patient care, and the impact of nursing documentation on financial reimbursement to the healthcare facility. It also identifies errors in documentation that might result in legal liability for the nurse.

Course Objectives:

After completion of this learning activity, the learner will be able to:

  • define documentation.
  • describe the importance of documentation in safeguarding and optimizing patient care.
  • describe the importance of documentation to financial reimbursement of healthcare facilities.
  • identify errors in documentation that might result in legal liability for the nurse.

Copyright© 2010 by HealthSoft, Inc. All Rights Reserved.

HealthSoft, Inc. is an approved provider of continuing nursing education by the New York State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

It has been assigned code 7SENNF-PRV-09.

This course is updated annually. Expiration date: 5/1/11

The faculty and planners of this course have no vested interests to disclose.

This course has received no commercial support.

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