Nursing: Documentation for Nurses, 3rd Edition

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About the Course

Nursing documentation is a critical component of all levels of nursing practice. Documentation allows nurses to account for the care which is provided by bringing together the available facts about nursing diagnoses, interventions, outcomes, and standards of care.  This course explores the underlying purposes of documentation, professional and regulatory requirements and processes, and best practices for adequate documentation, to accurately reflect the patient's severity of illness and transition for care.  Legal aspects and implications of documentation and strategies to reduce legal risk are addressed and principles and practices of defensible nursing documentation along with guidelines for improving documentation are highlighted.

Learning Outcomes:
Upon completion of this course, the learner will be able to:
  • Identify the importance and purpose of complete documentation in the medical record.
  • Discuss different nursing documentation methods and factors to consider in selecting a documentation system.
  • Discuss the evolution of computerized nursing documentation and requirements surrounding its use.
  • Identify the organizational, institutional, and legal standards and regulations that affect nursing documentation.
  • Describe documentation techniques and strategies to improve documentation.
  • Discuss steps in the nursing process to improve documentation.
  • Identify documentation considerations for specific areas of nursing practice and patient care.
  • Identify areas of nursing practice that pose a risk for legal consequences and the proper documentation techniques that can be used to mitigate that risk. 
  • Discuss the legal importance of, and nursing responsibilities in connection with, informed consent and the importance of the Patient Care Partnership.
  • Explain the need for incident reports in nursing practice and the proper method of documentation.
  • Describe documentation methods used in specific settings.
  • Discuss the role and function of advanced practice nurses and their documentation practices for quality metrics.

About the Author:
Kim Maryniak, PhD, MSN, BN, RNC-NIC, NEA-BC

Kim Maryniak, PhD, MSN, BN, RNC-NIC, NEA-BC, has more than 29 years of nursing experience with medical-surgical, psychiatry, pediatrics, progressive care, and adult and neonatal intensive care. She has been a staff nurse, charge nurse, educator, instructor, manager, and nursing director.  Dr. Maryniak graduated with a nursing diploma from Foothills Hospital School of Nursing in Calgary, Alberta, in 1989. She obtained her bachelor of science in nursing from Athabasca University, Alberta, in 2000, her master of science in nursing from the University of Phoenix in 2005, and her PhD in nursing from University of Phoenix in 2018. Dr. Maryniak is certified in neonatal intensive care nursing and as a nurse executive, advanced. She is active in the American Nurses Association, American Organization of Nurse Executives, and Sigma Theta Tau. Her current and previous roles include research utilization, nursing peer review and advancement, education, use of simulation, quality, process improvement, leadership and professional development, infection control, patient throughput, nursing operations, professional practice, and curriculum development.

Disclaimer: This course is presented by Elite Professional Education LLC.

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