Nursing: Documentation for Nurses, 4th Edition
45.95
Online
Elective
Please select your state to enroll in this course
About this Course

Nursing documentation is an integral part of clinical nursing care. This ensures that nurses account for the care that is provided and the resulting patient outcomes. Requirements for documentation in terms of regulatory, accreditation, and legal requirements are continually evolving, especially with the advent of electronic medical records.  This course emphasizes compliance with documentation for nurse accountability and performance evaluation. Incomplete, inadequate, or inaccurate documentation can adversely affect reimbursement and accreditation and have legal consequences that may expose the nurse to liability. Additionally, incomplete documentation can negatively affect communication and coordination of services between healthcare providers, which can in turn affect patient care.
Nurses commonly experience conflict between time spent caring for patients and time needed to accurately record care provided and a patient’s response to treatment. Documentation done using best practices accurately reflects the patient’s true clinical situation as well as trends toward recovery or complications. Inadequate or poor documentation may not tell the whole story of care or patient outcomes and could result in allegations of negligence, fraud, abuse, or malpractice. Good documentation can support workflow, improve efficiency, and increase productivity.

Learning Outcomes
After completing this course, the learner will be able to:
  • Identify the importance and purpose of complete documentation in the healthcare record.
  • Discuss different nursing documentation methods and factors to consider in selecting a documentation system.
  • Discuss the evolution of computerized nursing documentation and requirements surrounding its use.
  • Identify the organizational, institutional, and legal standards and regulations that affect nursing documentation.
  • Identify documentation considerations for specific areas of nursing practice and patient care that pose a risk for legal consequences and techniques that can be used to mitigate that risk.
  • Discuss the legal importance of, and nursing responsibilities in connection with, informed consent and the importance of the Patient Care Partnership.
  • Explain the need for incident reports in nursing practice and the proper method of documentation.
  • Discuss the role and function of advanced practice nurses and related documentation practices for quality metrics.

About the Author
Kim Maryniak, PhD, MSN, BN, RNC-NIC, NEA-BC

Kim Maryniak, PhD, MSN, BN, RNC-NIC, NEA-BC, has more than 31 years of nursing experience in critical care, professional practice, education and nursing operations, including as a Chief Nursing Officer. Her nursing experience spans medical/surgical practice, psychiatry, pediatrics, progressive care, and adult and neonatal intensive care. Dr. Maryniak graduated with a Nursing Diploma from Foothills Hospital School of Nursing in Calgary, Alberta, in 1989, obtained her Bachelor of Science in Nursing from Athabasca University, Alberta, in 2000, her Master of Science in Nursing from the University of Phoenix in 2005, and her PhD in Nursing from University of Phoenix in 2018. Dr. Maryniak is certified in neonatal intensive care nursing and as a nurse executive, advanced. She is active in the American Nurses Association and the American Organization of Nurse Leaders. Dr. Maryniak’s current and previous roles include research utilization, nursing peer review and advancement, education, use of simulation, quality, process improvement, leadership and professional development, infection control, patient throughput, nursing operations, professional practice, and curriculum development.

Dr. Maryniak has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book. 

About the Reviewer
Dr. Nicole Thomas, DNP, RN, CCM 

Dr. Nicole Thomas, DNP, RN, CCM is a full-time instructor of clinical nursing at Louisiana State University Health Sciences Center School of Nursing in New Orleans, LA.  She holds a Doctor of Nursing Practice with a specialization in healthcare systems leadership from Chamberlain University and a Master’s in Nursing Education from Walden University. Dr. Thomas is a certified case manager and community health nurse. She has devoted her nursing career to improving the quality of the delivery of healthcare for vulnerable populations and improving access to care for all communities. Dr. Thomas has participated, and currently participates, in multiple taskforces dedicated to improving quality healthcare delivery. Her research work focuses on improving hypertension management in African Americans utilizing self-efficacy and improving the delivery of healthcare from a community health perspective.

Dr. Thomas has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book. 

This course replaces Documentation for Nurses, 3rd Edition - N21661. 
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Documentation for Nurses, 4th Edition - N33914

45.95
About this Course

Nursing documentation is an integral part of clinical nursing care. This ensures that nurses account for the care that is provided and the resulting patient outcomes. Requirements for documentation in terms of regulatory, accreditation, and legal requirements are continually evolving, especially with the advent of electronic medical records.  This course emphasizes compliance with documentation for nurse accountability and performance evaluation. Incomplete, inadequate, or inaccurate documentation can adversely affect reimbursement and accreditation and have legal consequences that may expose the nurse to liability. Additionally, incomplete documentation can negatively affect communication and coordination of services between healthcare providers, which can in turn affect patient care.
Nurses commonly experience conflict between time spent caring for patients and time needed to accurately record care provided and a patient’s response to treatment. Documentation done using best practices accurately reflects the patient’s true clinical situation as well as trends toward recovery or complications. Inadequate or poor documentation may not tell the whole story of care or patient outcomes and could result in allegations of negligence, fraud, abuse, or malpractice. Good documentation can support workflow, improve efficiency, and increase productivity.

Learning Outcomes
After completing this course, the learner will be able to:
  • Identify the importance and purpose of complete documentation in the healthcare record.
  • Discuss different nursing documentation methods and factors to consider in selecting a documentation system.
  • Discuss the evolution of computerized nursing documentation and requirements surrounding its use.
  • Identify the organizational, institutional, and legal standards and regulations that affect nursing documentation.
  • Identify documentation considerations for specific areas of nursing practice and patient care that pose a risk for legal consequences and techniques that can be used to mitigate that risk.
  • Discuss the legal importance of, and nursing responsibilities in connection with, informed consent and the importance of the Patient Care Partnership.
  • Explain the need for incident reports in nursing practice and the proper method of documentation.
  • Discuss the role and function of advanced practice nurses and related documentation practices for quality metrics.

About the Author
Kim Maryniak, PhD, MSN, BN, RNC-NIC, NEA-BC

Kim Maryniak, PhD, MSN, BN, RNC-NIC, NEA-BC, has more than 31 years of nursing experience in critical care, professional practice, education and nursing operations, including as a Chief Nursing Officer. Her nursing experience spans medical/surgical practice, psychiatry, pediatrics, progressive care, and adult and neonatal intensive care. Dr. Maryniak graduated with a Nursing Diploma from Foothills Hospital School of Nursing in Calgary, Alberta, in 1989, obtained her Bachelor of Science in Nursing from Athabasca University, Alberta, in 2000, her Master of Science in Nursing from the University of Phoenix in 2005, and her PhD in Nursing from University of Phoenix in 2018. Dr. Maryniak is certified in neonatal intensive care nursing and as a nurse executive, advanced. She is active in the American Nurses Association and the American Organization of Nurse Leaders. Dr. Maryniak’s current and previous roles include research utilization, nursing peer review and advancement, education, use of simulation, quality, process improvement, leadership and professional development, infection control, patient throughput, nursing operations, professional practice, and curriculum development.

Dr. Maryniak has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book. 

About the Reviewer
Dr. Nicole Thomas, DNP, RN, CCM 

Dr. Nicole Thomas, DNP, RN, CCM is a full-time instructor of clinical nursing at Louisiana State University Health Sciences Center School of Nursing in New Orleans, LA.  She holds a Doctor of Nursing Practice with a specialization in healthcare systems leadership from Chamberlain University and a Master’s in Nursing Education from Walden University. Dr. Thomas is a certified case manager and community health nurse. She has devoted her nursing career to improving the quality of the delivery of healthcare for vulnerable populations and improving access to care for all communities. Dr. Thomas has participated, and currently participates, in multiple taskforces dedicated to improving quality healthcare delivery. Her research work focuses on improving hypertension management in African Americans utilizing self-efficacy and improving the delivery of healthcare from a community health perspective.

Dr. Thomas has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book. 

This course replaces Documentation for Nurses, 3rd Edition - N21661.