Medical Record Documentation & Legal Information for Certified Nursing Assistants

 

Certified nursing assistants, or CNAs, give important and valuable care in all types of settings. Just as important as the care you give is the documentation of that care. Additionally, you must be familiar with legal aspects of care that guide your practice as a CNA. This course will offer you guidance on documentation and legal aspects of care.

$20.00

Hours: 1.00
REL-SRC-0-MRDLICNA

Certificates

Certificates provided by accrediting body (5 Match)

Florida Board of Nursing - Certified Nursing Assistants

1.0 HOURS


This is not an accredited course for professional license renewal. Florida CNAs may use this inservice toward meeting their annual inservice requirement.This activity is approved for 1.00 contact hours.

Non-Licensed Direct Care (DSP, HHA, CNA, DCW, PCA, IHA, NA)

1.0 HOURS


North Carolina Department of Health and Human Services Division of Facility Services

1.0 HOURS


This course is approved by the North Carolina Department of Health and Human Services Division of Facility Services - Group Care Licensure Section (NC-DHHS)
Program Sponsor ID #032316; Approval # . This activity is approved for 1.00 contact hours.

California Department of Public Health (CNA)

1.0 HOURS


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 1.00 contact hours.

Washington State Department of Social and Health Services (ALL Direct Care Workers)

1.0 HOURS


Relias Learning, LLC is approved as a Curriculum Developer by the Washington State Department of Social and Health Services. This activity is approved for 1.00 contact hours for all WA State Direct Care Workers. Training Provider Code: WA0624. CE Approval Code: CO1731555

Course Details

Course Code: REL-SRC-0-MRDLICNA
Hours: 1
Type: Online Course
Content Expiration Date: 6/30/2023
Learning Objectives:
Identify the purpose of the medical record and documentation.

Explain guidelines regarding when and what to document.

Describe good documentation practices to avoid errors.

Identify legal standards that affect the certified nursing assistant.

Outline:
Section 1: Introduction
A. About This Course
B. Learning Objectives
Section 2: The Medical Record and Documentation
A. The Purpose
B. Electronic Medical Records
C. Importance of Documentation
D. When to Document
E. What to Document
F. Review
G. Summary
Section 3: Documentation Best Practices
A. Painting a Picture
B. One Simple Rule
C. Good Documentation
D. Mistakes and Late Entries
E. Objective vs. Subjective Data
F. Documenting Refusals
G. Change of Condition
H. Incomplete Documentation
I. Use of Inflammatory Language
J. Documentation Examples
K. Review
L. Summary
Section 4: Legal Standards
A. Laws and Rules
B. Regulation of CNA Practice
C. Scope of Practice
D. In-Service Requirements
E. Competency
F. Maintaining Certification
G. CNA Reporting Requirements
H. Policies and Procedures
I. Review
J. Summary
Section 5: Conclusion
A. Summary
B. Course Contributors
C. References
D. Congratulations!

Instructor: Cheryl Swann, RN-BC, BSN, WCC, LNHA
Cheryl Swann, RN-BC, BSN, WCC, LNHA has worked in long-term care for 20 years. Mrs. Swann has worked in many positions including Director of Nursing, Medicare Nurse Coordinator and Nursing Home Administrator. Cheryl is certified in both Gerontological nursing and wound care. In the past, she has assisted in the operations of multiple nursing facilities, including staffing, payroll, public health concerns, family member issues, management of consultant relationships (e.g. pharmacy, dietary, etc.), and as an intermediary between long-term care facilities and doctors. Mrs. Swann worked closely with federal monitors and the Office of Inspector General in developing an effective Continuous Quality Improvement and compliance program in her organization. Mrs. Swann has presented nationally regarding effective Quality Assurance, Restraint Reduction, Wound Prevention, CMS Five Star Quality Rating System and Developing a Corporate Compliance Program. Her expertise includes staff training and development, Quality Assurance and Performance Improvement initiatives, and policy development.  Disclosure: Cheryl Swann, RN-BC, BSN, WCC, LNHA has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Target Audience:
The target audience for this course is: entry level Direct Care Workers; in the following settings: Post-Acute Care.
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Course Delivery Method and Format
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
Relias has a grievance policy in place to facilitate reports of dissatisfaction. Relias will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias.
If you require special accommodations to complete this module, please contact Relias Support by completing the web form (https://www.relias.com/help) or by using the chat functionality.
All courses offered by Relias, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC.
All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
Accommodations
If you require special accommodations to complete this module, please contact Relias Customer Support by calling (800) 381-2321 or emailing support@relias.com