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Medical Record Documentation and Legal Aspects for Nursing Assistants
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.
This course will award 1 continuing education hour.
Please see the board approval box for course approvals.Course Objectives
- Explain the importance of accurate and timely medical record documentation.
- Identify essential legal requirements governing patient confidentiality and privacy.
- Demonstrate correct methods for recording patient observations and care interventions.
- Recognize common documentation errors and how to prevent them.
- Understand the nursing assistant’s role in protecting patients and healthcare providers through proper documentation practices.
Information
- Content Level: Intermediate
- Course Format: This course is offered as a self-paced distance learning format (reading-based online activity)
- System Requirements: This course is offered online. Internet connection required.
- Course Completion Information: To earn continuing education credit, professionals must register and pay the fee for the course. They must read the content and demonstrate understanding by earning a minimum score of 70 percent on testing materials. The certificate of completion will be able to be downloaded after the above is completed. Refunds will be granted upon request with the withdrawal of credit for the course. For questions, concerns, or to request special accommodations, please call 866-863-4225 or email ContactUs@BaysideCEU.com.
- CEBroker Course ID: 1295294
- Credit Hours: 1
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