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  • Nursing
  • Advanced Practice Nursing
Hours: 3 Contact Hours
Author(s): Kim Maryniak, RNC, BN, MSN, PhDc
Peer Reviewer(s): Chad A. Sullivan, RN, JD, CHC
Item#: N1690
Contents: 1 Course Book (48 pages)
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Documentation for Nurses: How and What to Document

Price $21.95
Item # N1690
When available, the Online Course format is included with the hard copy, eBook, or audio book formats!

Release Date: December 31, 2015

Expiration Date: December 31, 2018

Nursing documentation is a critical component of nursing practice. 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. Excellent documentation is not a substitute for providing nursing care, but excellent clinical care must be accompanied by appropriate documentation. Although the patient record is a permanent legal document that details nurse-patient interactions, it is not unusual to find critical omissions in nursing documentation as well as meaningless, repetitious, and inaccurate entries. Chapter 1 of this course presents characteristics of effective written communication, including documentation techniques and strategies to improve nursing documentation. In addition, rules for ensuring good documentation and patient confidentiality are presented.

Chapter 2 provides information pertaining to the use of the nursing process to improve nursing documentation, with hard evidence for a sound defense. While nursing documentation must be comprehensive and flexible enough to retrieve critical data, it must also reflect current clinical practice guidelines and track patient outcomes in order to maintain quality and continuity of care. A well-documented patient record is hard evidence that nurses can use to successfully defend themselves against legal action. In contrast, a poorly documented patient record can serve as powerful evidence in support of a suit, even when the accusations are trivial. 

The purpose of this course is to provide the nurse (including certified case manager nurses) with not only what should be documented but how nursing care delivered should be documented.


This course is an extraction of, and should not be taken in conjunction with,  N1634 Documentation for Nurses, 2nd Edition (15 contact hours).



This course has been submitted to the Commission for Case Manager Certification for approval to provide board certified case managers with 2 clock hours. Approval expires November 29, 2018.


Course Objectives

  • List five dos of documentation.
  • List five don’ts of documentation
  • Identify three techniques or strategies to improve documentation.
  • Discuss three rules for good documentation.
  • Describe four characteristics of effective written communication.
  • Explain the significance of the Health Infor­mation Portability and Accountability Act (HIPAA).
  • Identify patient confidentiality issues and ways to protect patient confidentiality.

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.