Nursing Documentation 101

Nursing Documentation 101 is organized by Nursing CE Central.

Course Created on: March 01, 2019
Course Renewed on: February 25, 2022
Course Expires on: February 25, 2025

Target Audience:
• Registered Nurses (RN)
• Advanced Practice Registered Nurses (APRN)
• Licensed Practical Nurses (LPN/LVN)

Course Overview:
Documenting is at best a useful tool for communication and at worst a necessary evil. It is well-known that documenting is one of the most tedious aspects of bedside nursing. It takes time away from patient care and may be used for (or against) you in court. In this CE module we will learn how to document properly. Proper documentation is an essential for defense against claims and continuity/quality of care in nursing.

Course Outline:
• Introduction
• The Who, What, When, Where, Why and How
• Privacy and Security
• The Legal Requirements
• When Documentation Becomes Your Defense
• The Cost
• What is Required for Nursing Documentation?
• Examples of Good and Bad Charting
• Common Documentation Errors
• Conclusion
• References

Course Objectives:
After completing this course, the learner will be able to:
• Describe best practices regarding documentation.
• Identify examples of proper and improper charting in everyday practice.
• Understand the importance of proper documentation.