Documentation for Nurses, 5th Edition


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About the Course: 
Nursing documentation is crucial for comprehensive patient care, ensuring accountability and compliance with evolving regulatory and legal standards, particularly with electronic medical records.  Furthermore, deficient documentation hampers communication among healthcare providers, affecting patient care. Despite time constraints, adhering to best practices in documentation accurately reflects patient status and treatment outcomes, while inadequate records may lead to allegations of negligence or malpractice. Effective documentation supports workflow, enhancing efficiency and productivity. This course emphasizes adherence to documentation for accountability and performance assessment, as incomplete or inaccurate records can impact reimbursement, accreditation, and legal liabilities.  

Learning Outcomes: 
Upon completion of the course, the learner will be able to:

  • Recognize the significance and objectives of comprehensive healthcare record documentation.
  • Examine various nursing documentation methods and factors influencing system selection.
  • Explore the development and usage requirements of computerized nursing documentation
  • Recognize the standards and regulations impacting nursing documentation at organizational, institutional, and legal levels.
  • Identify nursing documentation risks and mitigation techniques.
  • Examine the legal significance and nursing duties regarding informed consent. 


About the Author: 
Dr. Kim Maryniak, PhD, MSN, BN, RNC-NIC, NEA-BC, is a highly experienced nurse with over 31 years in critical care, professional practice, education, and nursing operations, including serving as a Chief Nursing Officer. Her specialties span various areas, including medical/surgical practice, psychiatry, pediatrics, progressive care, and adult and neonatal intensive care. Dr. Maryniak holds a nursing diploma from Foothills Hospital School of Nursing, her Bachelors of Science in Nursing from Athabasca University, and her Masters of Science in Nursing and PhD in Nursing from the University of Phoenix. She is certified in neonatal intensive care nursing and as a nurse executive, advanced. Actively involved in professional organizations, her roles include research utilization, education, quality improvement, leadership development, and curriculum development. Dr. Maryniak has no significant financial conflicts of interest.   

How to receive credit:

  • Read the entire course online or in print which requires a 17-hour commitment of time. 
  • 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 75% or higher is required. Exam questions link content to the course Learning Objectives as a method to enhance individualized learning and material retention. 
  • Provide required personal and payment information. 
  • Complete the mandatory course evaluation. 
  • Print your Certificate of Completion.



Resolution of Conflict of Interest 
Planners, faculty, and others in control of content (either individually or as a group) have no relevant financial relationships with ineligible companies. 

Sponsorship/Commercial Support and Non-Endorsement 
It is the policy of Colibri Healthcare, LLC not to accept support from ineligible companies. Furthermore, ineligible companies 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.  

©2024: 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. 

Accreditations and Approvals  
Colibri Healthcare, LLC is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.