Disciplines: Nursing
Hours: 10 Contact Hours
Item#: NLS10

Sign up for the Western Schools 365 Online Membership
Online Access to all our 1-15 hour nursing CE courses for a full year!

Nursing Documentation Bundle


Reg. Prices
Just $55.95
Item # NLS10
New
When available, the Online Course format is included with the hard copy, eBook, or audio book formats!

This product includes the following courses:
Click on the title to see more and read the course

Documentation for Nurses: The Essentials of Documentation

Price: $19.95 Hours:3 Contact Hours
Item # N1686  

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).

Documentation for Nurses: How and What to Document

Price: $19.95 Hours:3 Contact Hours
Item # N1690  

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 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).

Documentation for Nurses: Specialized Documentation

Price: $14.95 Hours:2 Contact Hours
Item # N1689  

Release Date: December 31, 2015

Expiration Date: December 31, 2018

Nurses use a variety of documentation methods, and some specific care areas require additional or particular kinds of documentation. Regardless of the method used for documentation, the medical record is always a formal, legal document that details a patient’s needs, interventions, evaluations, and progress. Nurses practicing in specialty areas, such as critical care, labor and delivery, and pediatrics to name only a few, utilize special documentation that focuses on the particular assessments, nursing interventions, and evaluations for the population.  This course presents information about these special area documentation requirements in several specific settings.  

In addition, the role of the advance practice registered nurse (APRN) has been rapidly growing in the recent decade.  Advanced practice nurses work in all 50 states in a variety of settings, including hospitals, nursing homes, businesses, private practices, schools, and community centers. Their documentation needs reflect the variety of settings and their vast role in providing care. This course defines the APRN, presents information about the differences between RNs and APRNs, and covers areas of specialization, governance, standards of practice, legal issues, and documentation requirements.


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

Documentation for Nurses: Types of Documentation

Price: $14.95 Hours:2 Contact Hours
Item # N1688  

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).

Want more choices?
Want more choices?