Purpose:The purpose of this course is to review documentation guidelines that are required in the clinical settings: long term care, home health agency, assisted living settings, hospital, physician’s office as well as clinics and other sites where patient care is being done. This course focuses on accuracy, legal requirements for nursing and CNA/HHA documentation within the patient’s medical record, appropriate documentation in patient’s Medical records and review of various formats for documentation.
After successful completion of this course the participants will be able to:
1. Describe the importance of completing accurate and complete documentation within the patient’s medical record
2.Explain the purposes for documentation
3.Discuss the Health Insurance Portability and Accountability Act, Privacy Rule.
4.Explain how to appropriately document errors,
5.Explain how to document continuations,
6.Explain how to document late entries.
7.Discuss the NANDA nursing diagnoses,
8.Describe the Nursing Interventions Classification (NIC),
9.Discuss the Nursing Outcomes Classification (NOC)
10.Describe various factors to consider in documentation.
11.Discuss characteristics of different formats for documentation
12.Discuss various components of computerized documentation systems.