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 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.
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.
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
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.
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
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.
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