Course Code: REL-ALL-0-MRDOCLIFLC
Hours: 1
Type: Online Course
Content Expiration Date: 12/31/2029
Learning Objectives:
Discuss the purpose of the medical record and documentation
Identify at least two documentation practices used to avoid errors.
Explain the legal standards that affect the certified nursing assistant.
Outline:
Section 1: Medical Record and Documentation
The Purpose
Technology and Documentation
Why? When? What?
Taking Fred’s Vital Signs
Review
Key Takeaways
Section 2: Best Practices for Documenting
How to Document
Objective or Subjective
Review
Change of Condition
Documentation Gone Bad
Review
Key Takeaways
Section 3: Legal Standards
Health and Safety
CNA Practice
Education and Training
Review
Key Takeaways
Section 4: Conclusion
Course Summary
Course Contributor
References
Subject Matter Expert: Bobbi Whittington, BSN, RN
Bobbi is currently an SME writer for Post-Acute Care at Relias. She began her nursing career as a Certified Nursing Assistant (CNA) in long-term care, where she discovered her passion for working with older adults in post-acute settings. In 1997, she earned her Licensed Practical Nurse (LPN) certification from South Central Area Vocational Technical School in Missouri. Demonstrating a commitment to advancing her education, she obtained an Associate Degree in Nursing from Texas County Technical Institute in 2007, followed by a Bachelor of Science in Nursing from Chamberlain College of Nursing in 2013. With more than 24 years of clinical and managerial experience in the skilled nursing industry, Bobbi has dedicated her career to enhancing the quality of care for older adults.
Target Audience:
The target audience for this course is: Direct Care Staff; in the following settings: All Healthcare Facilities.
Relias Learning will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Relias Learning has a grievance policy in place to facilitate reports of dissatisfaction. Relias Learning will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias Learning at support@reliaslearning.com.
Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.