Course Code: REL-ALL-0-MRDLIFCNA
Type: Online Course
Content Expiration Date: 8/31/2023
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.
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
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
Section 4: Legal Standards
A. Laws and Rules
B. Regulation of CNA Practice
C. Scope of Practice
D. In-Service Requirements
F. Maintaining Certification
G. CNA Reporting Requirements
H. Policies and Procedures
Section 5: Conclusion
B. Course Contributors
Faith Williams, RN, BS in HCA
Faith is a registered nurse and earned a BS in Health Care Administration at St. Leo College in St. Leo, Florida. She has an extensive background in home health education, nursing and healthcare administration. Subsequent to the years in home health, she has worked for companies who provide on-line education to healthcare providers and workers in the acute and subacute markets. She has authored various education programs and procedure manuals, as well as presented to and educated both clinical staff and the general public.
Disclosure: Faith Williams, RN, BS in HCA has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
The target audience for this course is: entry level Direct Care Workers; in the following settings: All Healthcare Settings.
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.
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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.
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