Documentation in the Electronic Age for Nurses
The purpose of this course is to identify various methodologies of electronic nursing documentation, explore dependency on standardized nomenclature to provide trending and analyzable data and outcomes for both the patient population and healthcare at large, as well as future innovations.
- Describe the major advantages and disadvantages of performing the appropriate method of documentation based on data composition.
- Demonstrate how value-added documentation can result in incentive reimbursement as a by-product of electronic documentation.
- Realize benefits and best practices of using electronic nursing documentation while minimizing challenges.
- Discuss measures that protect privacy, confidentiality, security, and authenticity with the use of electronic documentation.
- Adopt future initiatives in electronic documentation to further facilitate quality, efficiency, and safety.
About the Author
Catherine Turner, BSN, MBA, RN-BC, recognized early in her career the value that technology could bring to patients, care teams, and healthcare organizations. As an advocate of maximizing technology to provide safer care, she has lent her passion and expertise to the implementation, development, and marketing of MEDITECH's Electronic Health Record (EHR). Ms. Turner is well-known as a leader in the nursing informatics community. She is the Director of MEDITECH’s Nurse Informatics Program and spearheads the annual Nurse Conference. She is an active member and current co-chair of the HIMSS CNO-CNIO Vendor Roundtable Summit, served previously on the Corporate Advisory Board for the American Nurses Foundation, is a current member of the Healthcare Information Management System Society (HIMSS) and the American Nursing Informatics Association (ANIA), and represents MEDITECH's Nursing Informatics Program for the Alliance for Nursing Informatics (ANI). Ms. Turner has been a reviewer for a number of publications as well as a popular presenter at nationwide conferences and past content expert for AHIMA publications. She is a lecturer at the Northeastern University Bouvé College of Health Sciences Health Informatics Program and worked previously at the School of Nursing, having taught both programs in the classroom and online, as well as having taught and developed the course “Introduction to Health Informatics” at the University of Miami, FL for their Master’s in Health Informatics Program.How to Receive Credit:
- Read the entire course online or in print which requires a 3-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.
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.