Nursing Documentation: Quality, Technology, and Privacy
Hours: 1.00
Nurse documentation should be high quality, but what exactly does that mean? This course reviews the concepts of high-quality documentation and how that relates to technology and patient privacy. Most documentation takes place within electronic health records (EHRs) and nurses must understand how to practice high-quality documentation using these electronic methods. There are challenges with technology, but also lots of exciting developments that can improve nurse documentation. Technology also comes with concerns for breaches of confidentiality; nurses must know how to safeguard their nurse documentation and the EHR from unauthorized use.
Nurse documentation should be high quality, but what exactly does that mean? This course reviews the concepts of high-quality documentation and how that relates to technology and patient privacy. Most documentation takes place within electronic health records (EHRs) and nurses must understand how to practice high-quality documentation using these electronic methods. There are challenges with technology, but also lots of exciting developments that can improve nurse documentation. Technology also comes with concerns for breaches of confidentiality; nurses must know how to safeguard their nurse documentation and the EHR from unauthorized use.
American Nurses Credentialing Center
In support of improving patient care, Relias LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Nurses will receive 1.00 Nursing Contact Hours after successfully completing this course.
Apply criteria for high-quality documentation.
Describe technology’s impact on nursing documentation.
Review privacy and security issues with documentation.
Outline:
Section 2: Quality Documentation
Five Components of Quality Documentation
Best Practices for Quality Documentation
Cognitive Bias in Documentation
Improving Patient Outcomes and Safety
Section 4: Privacy and Security
Nurse Behaviors to Protect Patient Privacy
Writer: Sarah Hunter, RN, SCRN, CNRN, CMSRN
Ms. Hunter is a SME writer at Relias. Her area of expertise is neuroscience nursing, medical-surgical nursing, and thoracic surgery recovery. Ms. Hunter has worked at the bedside for 9 years in acute care and intermediate care neuroscience and intermediate care thoracic surgery at a large community hospital in North Carolina. She also served as chair of the hospital's shared governance council for Nursing Quality Improvement. She has a Bachelor of Arts and an Associate Degree in Nursing. Ms. Hunter is a Stroke Certified RN, Certified Neuroscience RN and a Certified Medical-Surgical RN.
Disclosure: Sarah Hunter, RN, SCRN, CNRN, CMSRN has no Relevant Financial or Non-Financial Relationship with ineligible companies to disclose.
The target audience for this course is: Nurses; in the following settings: Acute Care Facility.
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.
