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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
Self-study module - Ebook in PDF	$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
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
Complete Instruction Set  (4-CD set includes one self-study module on CD in Ebook format with reproducible test and scoring guidelines, interactive self-study CD-ROM, Instructor Slides and lesson plan for classroom presentation, learning reinforcement game ideas, Mind Maps and bonus word games useful for testing or learning reinforcement).	$55	Add to Cart
Instruction Mini-Kit All the same great training material EXCEPT the self-study module, contained on 3 CD's.  Test, lesson plan, Mind Maps, and word games in Word© format and ready to print. Self-study CD and instructor slides in PowerPoint©	$35	Add to Cart