Nursing Documentation

The purpose of this (2) hour course is to present key topics related to nursing documentation. Complete and legal nursing documentation is a critical component of nursing practice that is legally and ethically sound.

By the end of this course, you will have the skills to:

✔️ State the goals of documentation.

✔️ Explain the role of organizational policies and procedures in guiding documentation.

✔️ Identify documentation practices that validate safe, effective, and high-quality patient-centered care.

✔️ Identify documentation practices that create legal and professional risks.

✔️ Identify characteristics of nursing documentation that support a legal defense of nursing actions.

✔️ Identify employment and licensure implications of nursing documentation.

✔️ Explain nursing documentation requirements for specific aspects of care, including critical diagnostic results, medications, non-conforming patient behavior, pain, patient and family involvement in care, restraints, and prevention of falls, infections, pressure ulcers, and suicide.

✔️ Describe recommended documentation practices concerning communication with the patient’s provider and provider orders, such as questioning orders and receiving verbal orders.

✔️ Identify precautions to observe when using electronic documentation.