Documenting care is just as important as providing care. This course discusses the purpose of the medical record and documentation. It also describes documentation practices and legal standards that affect the certified nursing assistant.
This course provides direct care workers in post-acute care education on documentation and legal aspects of care.
Relias, LLC is an approved provider of continuing education by the California Department of Public Health, Provider # NAC7001.
The certificate must be retained by the licensee for a period of four (4) years after the course is completed.
This learning activity meets the definition of *** ONLINE *** CEUs. This activity is approved for 1.0000 contact hours.
This is not an accredited course for professional license renewal. Florida CNAs may use this inservice toward meeting their annual inservice requirement.
Outline:
Section 1: Medical Record and Documentation
The Purpose
Technology and Documentation
Why? When? What?
Taking Fred’s Vital Signs
Key Takeaways
Section 2: Best Practices for Documenting
How to Document
Objective or Subjective
Review
Change of Condition
Documentation Gone Bad
Review
Key Takeaways
Section 3: Legal Standards
Health and Safety
CNA Practice
Education and Training
Review
Key Takeaways
Section 4: Conclusion
Course Summary
Course Contributor
Resource
References
Bobbi began her nursing career as a CNA in long-term care and found her passion for working with older adults in the post-acute setting. She received her LPN certificate in 1997 from South Central Area Vocational Technical School in Missouri. Continuing her education, she earned her Associate Degree in Nursing in 2007 from Texas County Technical Institute in Missouri and later obtained her Bachelor of Science in Nursing from Chamberlain College of Nursing in 2013. Bobbi has over 24 years of clinical and managerial experience in the skilled nursing industry
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