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

The price of this course is $24.00. 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 (CEUs).

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.