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Goals and Learning Outcomes

This course will teach nurses all they need to know about the fundamentals of documentation. Documentation is the chief method of communication for all care provided to a patient during a stay at the hospital. High-quality documentation should reflect the excellence of care given to the patient. The concept of nurse documentation is simple, but it takes time and practice to develop the skill of documenting well. This course reviews the fundamentals of nursing documentation and how to include all significant nursing care into the patient’s health care record efficiently.


After taking this course, you should be able to:

  • Recall what nurse documentation is and what purpose it serves.
  • Determine what data should be documented and in what format.
  • Recognize the relationship between the nursing process and documentation.

Course Termination Date: Not yet determined

Content Expiration Date: 12/31/25

Course Originally Released On: 04/01/23

Course Authors

4.5 Average

Course Reviews

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Accreditation Information

NURSES

In support of improving patient care, Relias LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Provider approved by the California Board of Registered Nursing, CEP#13791

Disclaimer: Not all courses will provide California Board of Registered Nursing approval. Per California Assembly Bill No. 241, continuing education courses related to direct patient care shall address at least one or a combination of the following:(1) Examples of how implicit bias affects perceptions and treatment decisions of licensees, leading to disparities in health outcomes; or (2) Strategies to address how unintended biases in decision-making may contribute to health care disparities by shaping behavior and producing differences in medical treatment along lines of race, ethnicity, gender identity, sexual orientation, age, socioeconomic status, or other characteristics.

 

CEBroker

Relias LLC reports to CEBroker for the following boards (Provider # 50-1489): Arkansas State Board Of Nursing, District Of Columbia Board Of Nursing, Florida Board Of Nursing, Georgia Board Of Nursing, New Mexico Board Of Nursing, South Carolina Board Of Nursing and  West Virginia Board Of Examiners For Registered Professional Nurses

 

Please check the licenses/certifications section under my account (after logging in) to make sure you have entered a valid license number. This information is required for correct reporting of your course completions to CE Broker.

 

Disclosures

None of the planners/faculty, unless otherwise noted, for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.