Electronic Nursing Documentation: Best Practices and Future Trends
Course Overview
This course examines the evolution of nursing documentation from paper records to electronic health records (EHRs) and the impact of digital systems on clinical practice. Learners will explore the purpose and uses of nursing documentation, including communication, regulatory compliance, reimbursement, and quality improvement. Key documentation methods are reviewed, along with the role of standardized terminology in supporting data analysis and clinical decision-making.
The course offers practical strategies for applying best practices, reducing documentation burden, and maintaining privacy, confidentiality, and data security. Emerging technologies and future trends in electronic documentation are introduced to highlight their role in improving efficiency, patient safety, and care outcomes.
Learning Outcomes
Upon the completion of this course, the learner should be able to:
- Compare documentation methods across their historical development, including the advantages and disadvantages of each.
- Analyze how value-added electronic documentation can support organizational reimbursement.
- Implement best practices for using electronic nursing documentation to maximize benefits and minimize challenges.
- Assess measures that protect privacy, confidentiality, security, and authenticity when using electronic documentation.
- Evaluate future initiatives in electronic documentation for their potential to improve quality, efficiency, and safety.
About the Author/Presenter
Kim Maryniak,?PhD, FNP-C, RNC-NIC, NEA-BC?has more than 37?years of nursing experience across acute care, long-term care, nursing leadership, education, quality improvement, neonatal intensive care, and family medicine. She is?certified as a Family Nurse Practitioner, in Neonatal Intensive Care Nursing, and as a Nurse Executive, Advanced,?and has?been?writing professionally since 2011.?
Audience/Accreditations and Approvals
TRC Healthcare/ NetCE
In support of improving patient care, this activity has been planned and implemented by TRC Healthcare/ NetCE. TRC Healthcare/NetCE 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.
This course is designed for the following healthcare professions (select your profession for details):
Nursing
If you require special accommodations, please contact Colibri Healthcare Support by clicking here: Contact Us
