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  • Nursing
  • Advanced Practice Nursing
  • Psychiatric Technician
Hours: 20 Contact Hours
Author(s): Kim Maryniak, PhD, MSN, BN, RNC-NIC, NEA-BC
Peer Reviewer(s): Emily J. Gesner, DNP, RN-BC
Item#: N1882
Contents: 1 Course Book (258 pages)
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Documentation for Nurses, 3rd Edition

Price $64.95
Item # N1882
When available, the Online Course format is included with the hard copy, eBook, or audio book formats!

Hard Copy Version Sold Out Until 3/8

Release Date: October 23, 2018

Expiration Date: October 31, 2021

Nursing documentation is a critical component of nursing, for 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, which 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. Principles and practices of defensible nursing documentation along with guidelines for improving documentation are highlighted.

Course Objectives

  • 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.

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.

Emily J. Gesner, DNP, RN-BC, is an adjunct professor of nursing and healthcare informatics at Bouvé College of Health Sciences at Northeastern University in Boston, Massachusetts. She holds a doctor of nursing practice from Northeastern University and a master’s degree in nursing informatics from Excelsior College in Albany, New York. Dr. Gesner is American Nurses Credentialing Center certified in informatics nursing. She has spent many years creating and maintaining electronic versions of clinical documentation in large healthcare systems, including Cape Cod Healthcare and Partners Healthcare. She has participated in workgroups to standardize and improve the quality of documentation across all disciplines. Her research work focuses on the federal policies surrounding required clinical documentation and quality of care. Dr. Gesner has authored and coauthored multiple national and international peer-reviewed articles discussing the process of standardizing electronic clinical documentation. Dr. Gesner also serves as a nurse planner for Western Schools.

  • 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.