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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#: N1686
Contents: 1 Course Book (46 pages)
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Documentation for Nurses: The Essentials of Documentation

Price $21.95
Item # N1686
When available, the Online Course format is included with the hard copy, eBook, or audio book formats!

Release Date: December 30, 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. Accurate documentation of patient symptoms and observations is critical to the proper treatment and recovery of patients, as nursing documentation of patient care is essential for effective communication among healthcare providers.

Nurses acknowledge early in their training and practice that complete and proper documentation is required and necessary; however they may find documentation burdensome and time consuming even in this age of electronic documentation. Nurses commonly experience conflict between spending time caring for patients and spending time accurately recording the care provided and the patient’s responses to treatment. When time is limited, nursing care may take priority and what is documented may not tell the entire story.

Nursing documentation may be easier now with the development of standardized care plans, but it is still essential to individualize the care plan for each patient. Numerous accreditation and federal standards and regulations that govern the nursing documentation process must also be followed. 

This course introduces the essentials to accurate and thorough nursing documentation of patient care. The nurse will be able to identify the purposes of a patient health records and specific forms used by nurses in documenting care provided. The nurse will also be able to describe those standards and regulations that guide nursing documentation and their implications in nursing practice. The course is geared toward any registered nurse practicing in a general staff field.


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 3 clock hours.

Course Objectives

  • Identify the importance and purpose of complete documentation in the medical record
  • Identify professional, accreditation, and regulatory requirements for documenting patient care.

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.