Disciplines:
  • Nursing
  • Advanced Practice Nursing
Hours: 2 Contact Hours
Author(s): Kim Maryniak, RNC, BN, MSN, PhDc
Peer Reviewer(s): Chad A. Sullivan, RN, JD, CHC
Item#: N1688
Contents: 1 Course Book (44 pages)
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Documentation for Nurses: Types of Documentation



Price $16.95
Item # N1688
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

Over the years, numerous documentation methods have evolved, changing the way nurses document. Methods to decrease the amount of time required for documentation have been developed and implemented in a variety of settings. Likewise, institutions have adopted and even modified certain methods for documentation to fit their specific needs. This course presents commonly used methods of documentation, which hospitals and healthcare settings have adopted for their specific needs.

Another advancement in nursing documentation is computerized documentation. Computerized information systems are becoming the norm in most healthcare facilities. Inputting nursing data into computerized information systems requires defining and structuring the data to fit the parameters of a computer without losing the essence of nursing. This course describes the evolution of computerized documentation, its advantages and disadvantages, implementation and education requirements, legal concerns, and predictions for the future.

The purpose of this course is to introduce the methods of documentation and the introduction of computerized systems into nursing documentation.  The nurse will be able to identify the various methods implemented in a variety of settings as well as the advantages and disadvantages of computerized documentation. 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

  • Discuss different nursing documentation methods and cite the advantages and disadvantages of each method.
  • Discuss the move toward computerized nursing documentation.
  • Describe at least three requirements regarding use of computerized nursing documentation.

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.

  • Contact hours will be awarded for up to one (1) year from date of purchase or through the expiration date indicated above, whichever date comes first.
  • 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.