Documentation for Nurses, 4th Edition

About the Course:
Nursing documentation is an integral part of clinical nursing care. This ensures that nurses account for the care that is provided and the resulting patient outcomes. Requirements for documentation in terms of regulatory, accreditation, and legal requirements are continually evolving, especially with the advent of electronic medical records.  This course emphasizes compliance with documentation for nurse accountability and performance evaluation. Incomplete, inadequate, or inaccurate documentation can adversely affect reimbursement and accreditation and have legal consequences that may expose the nurse to liability. Additionally, incomplete documentation can negatively affect communication and coordination of services between healthcare providers, which can in turn affect patient care.
Nurses commonly experience conflict between time spent caring for patients and time needed to accurately record care provided and a patient’s response to treatment. Documentation done using best practices accurately reflects the patient’s true clinical situation as well as trends toward recovery or complications. Inadequate or poor documentation may not tell the whole story of care or patient outcomes and could result in allegations of negligence, fraud, abuse, or malpractice. Good documentation can support workflow, improve efficiency, and increase productivity.

Learning Outcomes
After completing this course, the learner will be able to:
  • Identify the importance and purpose of complete documentation in the healthcare 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.
  • Identify documentation considerations for specific areas of nursing practice and patient care that pose a risk for legal consequences and 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.
  • Discuss the role and function of advanced practice nurses and related documentation practices for quality metrics.

About the Author
Kim Maryniak, PhD, MSN, BN, RNC-NIC, NEA-BC, has more than 31 years of nursing experience in critical care, professional practice, education and nursing operations, including as a Chief Nursing Officer. Her nursing experience spans medical/surgical practice, psychiatry, pediatrics, progressive care, and adult and neonatal intensive care. Dr. Maryniak graduated with a Nursing Diploma from Foothills Hospital School of Nursing in Calgary, Alberta, in 1989, 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 and the American Organization of Nurse Leaders. Dr. Maryniak’s 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.

This course replaces Documentation for Nurses, 3rd Edition - N21661. 

How to Receive Credit:
  • Read the entire course online or in print which requires a 15-hour commitment of time.
  • Complete the Self-Assessment Quiz Questions either integrated throughout or all at the end of the course.
    • These questions are NOT GRADED. The questions are included to help affirm what you have learned from the course.
    • The correct answer is shown after the question is answered. If the incorrect answer is selected, a Rationale for the correct answer is provided.
  • At the end of the course, answer the Yes/No Affirmation question to indicate that you have completed the educational activity.
  • Specific to Florida: A mandatory Final Examination with a passing score of 70% or higher is required. Exam questions link content to the course Learning Objectives as a method to enhance individualized learning and material retention.
  • If requested, provide required personal and payment information.
  • Complete the mandatory Nursing Course Evaluation.
  • Print your Certificate of Completion.


Resolution of Conflict of Interest

In accordance with the ANCC Standards for Commercial Support for continuing education, Colibri Healthcare, LLC implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity.

Sponsorship/Commercial Support and Non-Endorsement
It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition ©2021: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Colibri Healthcare, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up-to-date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers.

Course Verification
All individuals involved have disclosed that they have no significant financial or other conflicts of interest pertaining to this course. Likewise, and in compliance with California Assembly Bill No. 241, every reasonable effort has been made to ensure that the content in this course is balanced and unbiased.