Nursing Documentation
Certificates
California Board of Registered Nursing
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
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
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
Florida Board of Nursing CE Provider #: 50-290
Nurses will receive 1.00 contact hours for participating in this course.
Georgia Board of Nursing
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
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
New Mexico Board of Nursing
New Mexico Board of Nursing (CEBroker Provider # 50-290)
This course awards 1.00 contact hours upon successful completion.
Arkansas State Board of Nursing
Course Details
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
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.
The target audience for this course is: Nurses; in the following settings: Post-Acute Care.
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.
If you require special accommodations to complete this module, please contact Relias Customer Support here.
