Introduction
Purpose of Documentation
Confidentiality
Charting Concerns
Charting Errors
Minimizing Risk
Format for Charting
Principles of Nursing Documentation
Summary
INTRODUCTION
Nursing documentation is both necessary and challenging. Nurses continue to chart using various methods. Depending on your place of employment, you may still be using paper charting, but many facilities have made the switch to computerized charting. Some are more effective than others but what does not change is the importance of what we document in the medical record. A few issues seem to present continuously. Some of the issues may be time related, but some result from poorly developed habits. What you document in the patient’s medical record is a record of the care you give. It reflects your professionalism and ability to think critically. It shows that you know and understand the nursing process. This CNE activity is designed to identify some known problem areas and provide strategies to positively improve documentation.
Disclosure to Participants
Approval Statement:
Ames Heigh LLC is approved as a provider of nursing continuing professional development by New Mexico Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.
Requirements for Successful Completion:
Learning outcome:
The learner outcome will be measured as evidenced by registered nurses increased knowledge and ability to accurately and completely document patient care in the medical health record.
To receive contact hours for this continuing education activity, the participant must:
- Complete the learner -paced learning activity
- Successfully complete the post test with a score of 75% or better
- Complete and submit the evaluation form
Once successful completion has been verified, a “Certificate of Successful Completion” will be awarded for 1.2 contact hours.
Individuals in a position to control content have no financial relationship to mitigate.
Expiration Date for Awarding Contact Hours:
This activity expires July 31, 2024.
Course Information
Course Instructor
