Medical Documentation

Contact Hour(s): 

2 Contact Hours

Author:

David Tilton, RN, BSN

This peer-reviewed course is applicable for the following professions:

Advanced Practice Registered Nurse (APRN), Athletic Trainer (AT/AL), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Dietetic Technicians, Registered (DTR), Dietitian/Nutritionist (RDN), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Respiratory Care Practitioner, Respiratory Therapist (RT)

Accreditations: 

The American Nurses Credentialing Center (ANCC), The American Occupational Therapy Association (AOTA), Board of Certification for Athletic Trainers (BOC)

State Approvals:

Alabama, Provider #ABNP1485; California BRN Provider #CEP # 13509; Florida Physical Therapy Association Approval: CE26-1116772; Kentucky Board of Nursing Provider #7-0085; Florida Board of Nursing Provider 50-353; Nevada Board of Physical Therapy; New York State Education Department’s State Board for Physical Therapy

Course Description:

This course is aimed at improving healthcare professionals’ knowledge of medical record documentation requirements and professional, responsible documentation strategies as well as defensible documentation strategies.

Outcomes:

≥92% of participants will have improved knowledge of medical record documentation requirements and professional, responsible documentation strategies.

Objectives:

After completing this continuing education course, the participant will be able to:

At the completion of this course, the participant will be able to:

1. Identify at least one Joint Commission documentation guideline.
2. List four abbreviations listed on the Joint Commission’s “do not use” abbreviation list.
3. Describe two different documentation styles.
4. Identify three progress note formats.
5. Apply two strategies to avoid legal problems with documentation.

Disclosures:

CEUFast Inc. and the course planning team for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.