This program covers the following topics:

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Purposes of the clinical/medical record

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Clinical/medical record formats and styles

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Health care trends affecting nursing documentation (or clinical documentation)

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Nursing documentation guidelines/standards

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Do's and Don'ts of nursing documentation

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Samples of nursing documentation errors

 

Documenting Clinical Care

 

 

 

 

 

 

 

 

  

 

 

                                    

 

 

 

 

 

 

Learner Objectives

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

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

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

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

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

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

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

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

 

 

 

 

 

 

 

 

 

 

Formats Available

Cost

Buy

Documenting Clinical Care - self-study module

$50    

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Documenting Clinical Care - interactive self-study CD

$20

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Documenting Clinical Care - Instructor Slide Presentation on CD

$12 

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Documenting Clinical Care - Instructor Slide Presentation on 3.5" disk

$10  

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Complete Instruction Set -The complete instructor's kit on Documenting Clinical Care includes one self-study packet with reproducible test and scoring guidelines, CD-ROM version for self-study, Instructor Slide Presentation  and lesson plan for classroom presentation, learning reinforcement game ideas, Mind Maps and bonus word games useful for testing or learning reinforcement).

$75

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 Instruction Mini-Kit

All the same great training material EXCEPT the self-study module, contained on 3 CD's.  Test, lesson plan, MindMaps, and word games in Wordİ format and ready to print. Self-study CD and instructor slides in PowerPointİ

$35

 

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