
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
-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 |
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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 |
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