Medical Record Documentation

Medical Record Documentation is organized by AchieveCE. This Course has been approved for a maximum of 1.0 Contact Hour.

Target Audience:
• Nursing
• Registered Nurse (RN)
• Advanced Practice Registered Nurse (APRN)
• Certified Nursing Assistant (CNA)
• Licensed Practical Nurse (LPN)

Course Overview:
Learn about the proper medical documentation in this CE that fulfills the CNA requirement for Medical Record Documentation & Legal Aspects.

Learning Objectives:
At the conclusion of this continuing education activity, the participant will be able to:
• Define medical documentation and its role in facilitating safe and effective patient care, ensuring reimbursement for services provided, and serving as a legal record of the patient’s treatment.
• Identify and compare commonly used charting styles, including narrative charting, PMOR, charting by exception, and clinical pathways.
• Identify common concerns surrounding computerized charting and steps that health care professionals should take to mitigate these concerns.
• Recall best practices in legally defensible charting.
• Recall how the Health Insurance Portability and Accountability Act protects sensitive health information.