Course Code: REL-PAC-0-DOCN
Hours: 1
Type: Online Course
Content Expiration Date: 12/31/2025
Learning Objectives:
Explain why detailed documentation is essential in healthcare.
Identify at least three methods of documentation.
Describe effective documentation strategies.
Outline:
Section 1: Introduction
About This Course
Learning Objectives
Section 2: Why is Documentation Essential?
Continuity of Care
Show Me the Money
Legal Implications
Barriers to Documentation
Review
Summary
Section 3: Many Ways to Tell a Story
Narrative Notes
Source-Oriented Documentation
Problem-Oriented Documentation
SOAPE Documentation
PIE Documentation
Focus Documentation or F-DAR
Charting By Exception
Flow Sheets
Electronic Health Records
Review
Summary
Section 4: Strategies for Effective Documentation
Handwritten and Electronic Documentation Techniques
Electronic Documentation Techniques
Think With Your Ink!
Review
Summary
Section 5: Documenting Health Conditions and Situations
Introduction
Urinary Tract Infection
Pain
Skin Conditions
COPD Exacerbation
Chest Pain
Falls
Medication Error
Refusal to Administer a Questionable Order
Verbal Orders
Review
Summary
Section 6: Conclusion
Course Summary
Course Contributor
Resources
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: Nursing Personnel; in the following settings: Skilled Nursing Facility.
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.
All courses offered by Relias Learning, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.