Documenting Clinical Care

This program covers the following topics:

Purposes of the clinical/medical record

Clinical/medical record formats and styles

Health care trends affecting nursing documentation (or clinical documentation)

Nursing documentation guidelines/standards

Do's and Don'ts of nursing documentation

Samples of nursing documentation errors

LEARNER OBJECTIVES

 

Upon completing this self-study program you should be able to:

-Identify the critical purposes of the (clinical) medical record.

-Define the characteristics of a (clinical) medical record entry that create an effective and legal entry.

-Examine and compare different styles and models of (clinical) medical record entries.

-List trends in health care today that impact written communication in the (clinical) medical record.

-Explain how legal and reimbursement problems occur due to omitted, altered, incorrect or incomplete documentation..

-List characteristics of clinical or nursing documentation that increase both legal and reimbursement risk.

-Differentiate between chart entries that do and do not meet the criteria of an effective and legal entry.

 

Formats Available

Cost

Buy
Order the CD's by mail:
Self-study module - Ebook in PDF on CD $20   Add to Cart
PowerPoint CD-ROM version for self-study

$20

 Add to Cart
Instructor slides (PowerPoint format) CD-ROM

$12 

 Add to Cart
Instructor files (lesson plan, test, scoring guide, learning reinforcement game ideas, Mind Maps and bonus word games useful for testing or learning reinforcement) $10 Add to Cart

Order all 4 CD's

    

Complete Instruction Set 

(4-CD set includes Ebook, interactive self-study CD-ROM, Instructor Slides and lesson plan, test, scoring guide, learning reinforcement game ideas, Mind Maps and bonus word games useful for testing or learning reinforcement).

 $55 Add to Cart

Instruction Mini-Kit

(3 CD set with all the same great training material EXCEPT the Ebook.)

 $35 Add to Cart

Printed self-study packet (for volume discounts contact NurseLearn at:

Phone: 405-745-2908  9-5 M-F CST

Fax: 405-745-2908

Email: marketing@nurselearn.com 

 

  $25
Add to Cart
Downloadable Versions    
 Self-study Ebook in PDF format $16
 Interactive Self-study program in PowerPoint format $16
 Instructor Slides in PowerPoint format $10
Instructor Files including the lesson plan, test, scoring guide, MindMaps and Word Games $8