Nursing Documentation

Nursing Documentation 

Sometimes the task of documentation can feel overwhelming. This course can help you improve your nursing documentation skills and explain what is essential to nursing documentation. You will also learn about legal implications in documentation, different documentation methods, situational documentation, and documentation of healthcare data. In the end, you will feel more confident about your documentation skills and value its purpose.

$20.00

Hours: 1.00
REL-PAC-0-ND

Certificates

Certificates provided by accrediting body (9 Match)

California Board of Registered Nursing

1.0 HOURS


Provider approved by the California Board of Registered Nursing, CEP# 13791

Nurses will receive 1.00 contact hours for participating in this course.

American Nurses Credentialing Center

1.0 HOURS


Relias, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Nurses will receive 1.00 contact hours for participating in this course.

District of Columbia Board of Nursing

1.0 HOURS


DC-RN -- District of Columbia Board of Nursing Approved Continuing Education program (CE Provider #50-290).

Nurses will receive 1.00 contact hours for participating in this course.

Florida Board of Nursing

1.0 HOURS


Florida Board of Nursing CE Provider #: 50-290

Nurses will receive 1.00 contact hours for participating in this course.

Georgia Board of Nursing

1.0 HOURS


Georgia Board of Nursing CE Provider #: 50-290

Nurses will receive 1.00 contact hours for participating in this course.

South Carolina Board of Nursing

1.0 HOURS


This program was approved by the South Carolina Board of Nursing Approved Continuing Education Program (CE provider #50-290) CE Broker Course # 20-[Custom_Code]

West Virginia Board of Registered Nursing

1.0 HOURS


New Mexico Board of Nursing

1.0 HOURS


New Mexico Board of Nursing (CEBroker Provider # 50-290)

This course awards 1.00 contact hours upon successful completion.

Arkansas State Board of Nursing

1.0 HOURS


Course Details

Course Code: REL-PAC-0-ND
Hours: 1
Type: Online Course
Content Expiration Date: 10/31/2022
Learning Objectives:
State why detailed documentation is essential in healthcare.
Identify various methods of documentation.
Examine effective documentation strategies.
Document pertinent information concerning commonly encountered situations and health conditions.

Outline:
Section 1: Introduction

About This Course

Learning Objectives

Section 2: Nursing Documentation in Healthcare

The Importance

Documentation is Essential in Healthcare

Barriers to Documentation

Legal Implications

Review

Summary

Section 3: Methods of Nursing Documentation

Narrative Notes

Charting by Exception

Flow Sheets

Source-Oriented Documentation

Problem-Oriented Documentation

SOAP Documentation

PIE Documentation

Focus (F-DAR) Documentation

Electronic Documentation

Review

Summary

Section 4: Effective Documentation Strategies

Documentation Techniques

Electronic Documentation Techniques

Handwritten Documentation Techniques

Review

Summary

Section 5: Situational Documentation

Informed Consent

Death of an Individual

Refusal to Administer a Questionable Order

Verbal Orders

Termination of Life Support

Review

Summary

Section 6: Documenting Common Health Conditions

Introduction

Urinary Tract Infection

Dizziness

Pain

Skin Conditions

Heart Failure Exacerbation

COPD Exacerbation

Pneumonia

Constipation

Chest Pain

Falls

Transient Ischemic Attack (TIA) and Cerebral Vascular Attack (CVA)

Review

Summary

Section 7: Conclusion

Summary

Course Contributor

Resources

References

Congratulations!

Exam and BrainSparks

Instructor: Kim Matthews, RN
Kimberly Matthews, RN obtained a nursing degree from Western Kentucky University in 1998.  Ms. Matthews possesses over 20 years of nursing experience with over 17 of those in the Skilled Nursing industry.  Ms. Matthews has extensive experience in MDS, restorative nursing programs, and nursing management.  Ms. Matthews is currently a Post Acute Care Content writer and subject matter expert for MDS. Disclosure: Kim Matthews, 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: Nurses; 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 here.