NUR115 - Nursing Documentation (1.5 HR)
Nurses will gain knowledge and skills related to the documentation of information in the patient’s medical record.
Purpose: Correct, proper, accurate, and timely documentation is one of the most important things for nurses in any capacity. It is often said, “If it wasn’t charted, it wasn’t done.” While that is true, charting tasks without doing them is also considered not done. Documenting appropriately proves you provided quality care and met nursing standards. Many times, it is also how facilities are reimbursed which ultimately affects how nursing staff are paid. Documentation is how we communicate with other members of the health care team, other entities, as well as the patients and their families. Correct and proper documentation is how nurses provide consistent, appropriate care and protects both our patients and us.
Objectives:
Define correct and proper documentation.
- Define correct and proper documentation.
- List at least five purposes of documentation.
- List several protocols and scenarios for different types of documentation.
- List the types of documentation.
- Discuss legal aspects of documentation.
Continuing Education Credits: 1.5 contact hours Iowa BON #335; 1.5 contact hours CA Board of Nursing CEP 14033; 1.5 contact hours CE Broker # 50-4572 Florida and District of Columbia; 0 contact hours for Social Work State of Illinois Department of Financial and Professional Regulation. License No. 159.001315; 0 contact hours for Physical Therapy State of Illinois Department of Financial and Professional Regulation. License No. 216.000284; 0 contact hours for Occupational Therapy State of Illinois Department of Financial and Professional Regulation. License No. 224.000164; 1.5 CE hours for long term care department heads; and other health care disciplines