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  • Nursing
  • Advanced Practice Nursing
Hours: 15 Contact Hours
Author(s): Kim Maryniak, RNC, BN, MSN, PhDc
Peer Reviewer(s): Chad A. Sullivan, RN, JD, CHC 
Item#: N1634
Contents: 1 Course Book (238 pages)
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Documentation for Nurses, 2nd Edition

Price $44.95
Item # N1634
When available, the Online Course format is included with the hard copy, eBook, or audio book formats!

Expiration Date: December 31, 2018

Nursing documentation is a critical component of nursing practice. Inadequate or poor documentation may result in the appearance of malpractice, negligence, fraud, or abuse. Documentation allows nurses to protect their careers by bringing together the best available facts about nursing diagnoses, interventions, and outcomes regarding the care provided to their clients. The purpose of this course is to explore the professional and regulatory requirements of documentation; to review documentation processes and systems; to acknowledge the impact of nursing documentation on patient care, the nursing career, and reimbursement; and to identify steps to avoid litigation. 

The book itself is divided into modules, covering multiple chapters. Thus, nurses can review modules of areas that are of interest to them. The chapters addressing legal aspects, preparation for deposition or trial, and documentation disasters, for example, provide nurses with helpful information that can be applied to multiple settings and roles. Other chapters address information about advanced practice nurse documentation and requirements, as well as specialized documentation. The goal of this course is to provide the principles and practices of defensible nursing documentation and guidelines for improving documentation, to prepare nurses for depositions and trials, and to prepare nurses to document as defensible evidence if they are involved in a lawsuit. 

Course Objectives

  • Identify professional and complete documentation elements in nursing care that comply with professional, accreditation and regulatory requirements
  • Discuss the various methods (electronic and paper) and types of nursing documentation, citing advantages and disadvantages of each
  • Discuss professional practices in nursing practice and documentation and legal implications, including professional liability insurance and preparing for legal proceedings
  • Identify legal documentation patient rights and directives as well as incident reports, focusing on purpose and requirements
  • Describe the purpose for specialized nursing documentation based on patient population and nursing focus

Kim Maryniak, RNC, BN, MSN, PhDc, has over 26 years nursing experience in medical/surgical, psychiatry, pediatrics, and neonatal intensive care nursing. She has been a staff nurse, charge nurse, educator, instructor, manager, and nursing director. Kim graduated with a nursing diploma from Foothills Hospital School of Nursing in 1989. She obtained her Bachelor in Nursing through Athabasca University in 2000 and her Master of Science in Nursing through University of Phoenix in 2005. Kim is certified in Neonatal Intensive Care Nursing and is currently pursuing her PhD in Nursing. She has been active in both the National Association of Neonatal Nurses and American Nurses Association. Kim’s current and previous roles have included professional development and practice, research utilization, nursing peer review and advancement, education, use of simulation, infection control, patient throughput, nursing operations, quality, and process improvement. She has developed educational activities for topics such as assessment, fundamentals of nursing, leadership, evidence-based practice, pain management, and specialty subjects.

Chad A. Sullivan, RN, JD, CHC, is a nurse attorney who received his Juris Doctorate from Louisiana State University in 2001. Prior to entering law school, Chad attended McNeese State University, where he obtained a Bachelor of Science in Nursing. He remains a licensed Registered Nurse in Louisiana. Chad received a certificate in Health Care Compliance from George Washington University in 2010 and is board certified in Health Care Compliance by the Health Care Compliance Association.

  • Courses must be completed on or before the expiration date noted in the course description above.
  • You must score 75% or higher on the final exam and complete the course evaluation to pass this course and receive a certificate of completion.
  • Through our review processes, Western Schools ensures that this course content is presented in a balanced, unbiased manner and is free from commercial influence. It is Western Schools’ policy not to accept commercial support.
  • All persons involved in the planning and development of this course have disclosed no relevant financial relationships or other conflicts of interest related to the course content.