Medical Record Documentation and Legal Information for CNAs
Documenting care is just as important as providing care. This course discusses the purpose of the medical record and documentation. It also describes documentation practices and legal standards that affect the certified nursing assistant.
This course provides direct care workers in post-acute care education on documentation and legal aspects of care.
Documenting care is just as important as providing care. This course discusses the purpose of the medical record and documentation. It also describes documentation practices and legal standards that affect the certified nursing assistant.
This course provides direct care workers in post-acute care education on documentation and legal aspects of care.
California Department of Public Health (CNA)
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 1.0000 contact hours.
Florida Board of Nursing - Certified Nursing Assistants
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 1.0000 contact hours.
Discuss the purpose of the medical record and documentation.
Identify at least two documentation practices used to avoid errors.
Explain the legal standards that affect the certified nursing assistant.
Outline:
Section 1: Medical Record and Documentation
The Purpose
Technology and Documentation
Why? When? What?
Taking Fred’s Vital Signs
Key Takeaways
Section 2: Best Practices for Documenting
How to Document
Objective or Subjective
Review
Change of Condition
Documentation Gone Bad
Review
Key Takeaways
Section 3: Legal Standards
Health and Safety
CNA Practice
Education and Training
Review
Key Takeaways
Section 4: Conclusion
Course Summary
Course Contributor
Resource
References
Bobbi is currently an SME writer for Post-Acute Care at Relias. She began her nursing career as a Certified Nursing Assistant (CNA) in long-term care, where she discovered her passion for working with older adults in post-acute settings. In 1997, she earned her Licensed Practical Nurse (LPN) certification from South Central Area Vocational Technical School in Missouri. Demonstrating a commitment to advancing her education, she obtained an Associate Degree in Nursing from Texas County Technical Institute in 2007, followed by a Bachelor of Science in Nursing from Chamberlain College of Nursing in 2013. With more than 24 years of clinical and managerial experience in the skilled nursing industry, Bobbi has dedicated her career to enhancing the quality of care for older adults.
The target audience for this course is: Direct Care Workers; 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.
