The Ins & Outs of Documentation

 

All healthcare organizations maintain various types of person-specific information in order to detail an individual’s health and care. This information can include observations and facts about the persons’ personal, medical, and social well-being. Specific federal regulations and best practice guidelines have been established to help healthcare organizations maintain the integrity of information in individuals’ medical records, including their care plans. These regulations and guidelines help ensure information entered into medical records is clear, concise, accurate, and individualized. Established guidelines also help streamline the documentation process to reduce errors and inconsistencies and increase an organization’s level of compliance. Because you are required to document information in medical records, it is vital that you know the importance of objective, consistent, and accurate documentation. In this course, you will learn about documentation best practices.

$20.00

Hours: 0.50
REL-SRC-0-IOD

Certificates

Certificates provided by accrediting body (0 Match)

Course Details

Course Code: REL-SRC-0-IOD
Hours: 0.5
Type: Online Course
Content Expiration Date: 2/28/2022
Learning Objectives:
List the basics of documentation
Identify who is responsible for documentation
Describe the need to document objectively
Discuss how the care plan pertains to proper documentation.

Outline:
Section 1: Introduction
A. About This Course
B. Learning Objectives
Section 2: The Basics of Documentation
A. Why Is It Important?
B. Putting Documentation Skills in to Practice
C. Documenting Factual and Objective Information
D. Individualized and Accurate
E. Review
Section 3: Conclusion
A. Summary
B. Congratulations!
C. Course Contributor

Instructor: Karen C. Schnaufer, BSN, RN
Karen C. Schnaufer, BSN, RN, Content Writer, Relias Learning, has held positions as staff nurse, charge nurse, research nurse clinician, and clinical instructor with over 25 years of clinical practice in a broad range of specialties: med/surg, pediatrics, long term care, mental health, research, and IDD. Prior to becoming a Registered Nurse, Ms. Schnaufer successfully challenged the Practical Nursing Boards in NY. After working with the Breast Oncology Research group at Duke, Ms. Schnaufer switched her focus to the area of IDD and worked with individuals with intellectual disabilities and mental health issues, who live in group homes. Among her various responsibilities in this area was to train direct support staff and clinicians in medical issues/medication administration, participate in state surveys, providing and implementing plans of correction, as well as, serving on various committees, such as Human Rights, to help improve the lives of the individuals supported. To this day, she continues to volunteer in this realm. A veteran of the U.S.A.F., Ms. Schnaufer is committed to creating relevant and intelligent continuing education courses for healthcare professionals throughout the continuum of care. Disclosure: Karen C. Schnaufer, BSN, RN 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; entry level General Staff; in the following settings: Post-Acute Care.
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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 [email protected]