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. This course will give general information that is appropriate to all CNAs in Florida. It is also important for you to be familiar with and follow your organization’s policies and procedures.
This is not an accredited course for professional license renewal. Florida CNAs may use this inservice toward meeting their annual inservice requirement.
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!
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 no Relevant Financial or Non-Financial Relationship with ineligible companies to disclose.
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