Documentation for Nurses

Course Code: REL-PAC-0-DOCN

Hours: 1

Type: Online Course

Content Expiration Date: 12/31/2025

Learning Objectives:
Explain why detailed documentation is essential in healthcare.
Identify at least three methods of documentation.
Describe effective documentation strategies.

Outline:
Section 1: Introduction

About This Course

Learning Objectives

Section 2: Why is Documentation Essential?

Continuity of Care

Show Me the Money

Legal Implications

Barriers to Documentation

Review 

Summary

Section 3: Many Ways to Tell a Story

Narrative Notes

Source-Oriented Documentation

Problem-Oriented Documentation

SOAPE Documentation

PIE Documentation

Focus Documentation or F-DAR

Charting By Exception

Flow Sheets

Electronic Health Records

Review 

Summary

Section 4: Strategies for Effective Documentation

Handwritten and Electronic Documentation Techniques

Electronic Documentation Techniques

Think With Your Ink!

Review 

Summary

Section 5: Documenting Health Conditions and Situations

Introduction

Urinary Tract Infection

Pain

Skin Conditions

COPD Exacerbation

Chest Pain

Falls

Medication Error

Refusal to Administer a Questionable Order

Verbal Orders

Review 

Summary

Section 6: Conclusion

Course Summary

Course Contributor

Resources

References

Subject Matter Expert: Bobbi Whittington, BSN, RN

Bobbi is currently an SME writer for Post-Acute Care at Relias. She began her nursing career as a Certified Nursing Assistant (CNA) in long-term care, where she discovered her passion for working with older adults in post-acute settings. In 1997, she earned her Licensed Practical Nurse (LPN) certification from South Central Area Vocational Technical School in Missouri. Demonstrating a commitment to advancing her education, she obtained an Associate Degree in Nursing from Texas County Technical Institute in 2007, followed by a Bachelor of Science in Nursing from Chamberlain College of Nursing in 2013. With more than 24 years of clinical and managerial experience in the skilled nursing industry, Bobbi has dedicated her career to enhancing the quality of care for older adults.

Target Audience:
The target audience for this course is: Nurses; in the following settings: Post-Acute Care.

Relias Learning will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.

Relias Learning has a grievance policy in place to facilitate reports of dissatisfaction. Relias Learning will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias Learning at support@reliaslearning.com.

All courses offered by Relias Learning, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.

To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.

Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.