The Best Defense Is a Good Documentation Offense
(3.8 Contact Hours)

_______________________________________________________________ "If it's not in the medical record, it didn't occur." Barbara E. Calfee, Nurses in the Courtroom: Cases and Commentary for Concerned Professionals _______________________________________________________________

Written By: Dana Wetter, M.Ed., RN, C

To successfully complete this course and receive your certificate, you must read the content online, pass the post test with a 70% or better, and complete the online evaluation form.

The price of this course is $28.00. You will only be asked to pay for the course if you decide to grade the post examination to earn a certificate with contact hours.

This activity was developed by Corexcel without support from any commercial interest.

It is Corexcel's policy to ensure fair balance, independence, objectivity, and scientific rigor in all programming. In compliance with the American Nurses Credentialing Center (ANCC) we require that faculty disclose all financial relationships with commercial interests over the past 12 months.

No planning committee member has indicated a relevant financial relationship with a commercial interest involved with the content contained in this course.

Corexcel's provider status through ANCC is limited to educational activities. Neither Corexcel nor the ANCC endorse commercial products.

All materials contained in this educational activity are protected by United States copyright law and may not be reproduced, distributed, transmitted, displayed, published or broadcast without the permission of Corexcel. You may not alter or remove any trademark, copyright or other notice from copies of the content.

 

Program Objectives

After completion of The Best Defense Is A Good Documentation Offense, the participant will be able to:

1. Explain the importance of documentation as a health care provider.

2. Identify the basic information that is required when documenting in the medical record.

3. Describe those particular issues that require documentation in the medical record.

4. Discuss the emerging documentation concerns regarding the faxing and computerization of records.

5. Determine documentation Do's and Don'ts.

6. Compare differences in documentation issues that are specific to nurses versus certified nursing assistants.

7. State the characteristics of satisfactory documentation.

8. Evaluate the medical record documentation issues in selected legal cases.

9. Explain how documentation may evolve in the future to meet emerging needs.