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NOTE: This course provides less than 1 hour of continuing education credit and will not be accepted in states that require CE courses to provide a minimum of 1 hour of continuing education in a single learning session (e.g., Florida). For information on current CE requirements in your state, consult your state's licensure board for nurses.

This course provides nurses and other healthcare professionals with background information on nursing documentation techniques and requirements.

No commercial support was provided for the development of this activity.

STATEMENT OF NEEDThe role of a nurse is complex and legally accountable. The nurse is charged with assessing patients, giving medications, providing treatments, helping with hygiene, teaching about nutrition and various diagnoses, planning for discharge, and listening to fears and concerns of the patient as well as the family. This course is designed to familiarize you with nursing essentials that you will use to perform your duties every day.

To complete this activity and obtain CE credit, you must do the following:

  • Read this Course Introduction / Disclosure section in its entirety.
  • Read the course material.
  • Complete the Post Test with a score of 80% or more.
  • Submit the online activity evaluation form.

    Medcom/Trainex is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation*

    Medcom/Trainex is accredited as a provider of continuing nursing education by the California Board of Registered Nursing (provider number CEP 9888), and the Florida Board of Nursing (provider number 50-1285).

    *Accreditation refers to recognition of educational activities only and does not imply Commission on Accreditation approval or endorsement of any product.

    CREDIT DESIGNATIONMedcom, Inc. designates this educational activity for 0.5 contact hour of continuing nursing education credit.

    This course reviews the essentials of the charting and documentation process within a patient medical record, including legal aspects. The material is organized around the following categories:

  • Introduction
  • Functions of a Patient Medical Record
  • Types of Documentation
  • Documentation Process
  • Caveats
  • Pitfalls
  • Special Circumstances: Verbal Orders
  • Legal Aspects of Documentation
  • Conclusion

    LEARNING OBJECTIVESAfter completing this course, the learner should be able to:

  • Describe the functions of medical records.
  • Describe five commonly used approaches to documentation.
  • LIst the most common types of documenting mistakes and sources of inaccuracy.
  • Explain the importance of maintaining patient confidentiality.
  • Describe strategies to preserve patient confidentiality at all times.
  • Explain how to address issues related to noncompliance, unusual occurrence reports, and administrative considerations.

    This educational activity was wholly developed, written, and produced by Medcom, Inc., G. Rand Rodriguez, editor. Ruth Kramer, RN, MSN served as subject matter expert and performed a content validation review. Marguerite T. Voorhees, RN, MN, CNS, CPHQ, CPHRM served as nurse planner.

    In accordance with ANCC Standards, parallel documents from other accrediting bodies, and Medcom, Inc. policy, the learner is hereby informed that the planners and staff of Medcom, Inc., and the content validation reviewer(s) involved with this activity have reported no relevant financial relationships with commercial interests. Furthermore, there is no discussion in this activity about the use of products for non FDA-approved indications.

    UNAPPROVED USE DISCLOSUREMedcom, Inc. requires authors and content validation reviewers to disclose to the learner when products or procedures being discussed are off-label, unlabeled, experimental, and/or investigational (not FDA approved); and any limitations on the information that is presented, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion. Authors of this activity may present information about pharmaceutical agents that is outside of U.S. Food and Drug Administration approved labeling. This information is intended solely for continuing medical education and is not intended to promote off-label use of these medications. If you have questions, contact the medical affairs department of the manufacturer for the most recent prescribing information.

    As in all educational activities, we encourage the practitioners to use their own judgment in treating and addressing the needs of each individual patient, taking into account the patient's unique clinical situation. Medcom disclaims any liability and/or loss resulting from the information contained in this activity. The learner specifically agrees to indemnify and hold Medcom, the creators, producers, and distributors of this activity harmless against any and all claims or liabilities arising out of the use of any information provided in this activity by the learner, or by anyone directly or indirectly obtaining such information through the learner.

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    Documentation: The Process Online course
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