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Accurate medical record documentation is a vital skill for nurses and nursing assistants, bridging patient care with clear, concise communication and ensuring legal compliance within healthcare facilities. This course provides foundational knowledge and practical techniques necessary to effectively record patient information, adhere to confidentiality standards, and recognize the legal implications of documentation practices. Participants will explore best practices for maintaining thorough, accurate records, understand their role in safeguarding patient privacy, and gain essential insights into how meticulous documentation can protect both patients and healthcare providers.