Though not a therapy or course of treatment, documentation is a critical component of providing nursing care. Whether electronically or in print, the recording of a patient's condition, treatment and response to treatment, provides the crucial information needed by each members of the patient’s healthcare team that allows them to provide their specialized care. In addition to assisting with patient care, it can protect the nurse from legal action by demonstrating that needed care was provided.

This two-part series on documentation provides nurses and others with an understanding of the importance of accurate and objective charting in order to assist the patient's continuing care, and of the legal and administrative considerations related to healthcare documentation.

The programs in the series provide a total of 1 hour of continuing nursing education.

Overview

Documentation of patient care using electronic medical records (EMR) has become method preferred by many healthcare organizations and is both encouraged and mandated by the federal government. This program provides the nurse with an understanding of EMRs advantages that can be of benefit, and potential disadvantages that must be avoided and addressed. In addition it will provide an overview of the impact of federal mandates such as the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) act on EMR.

After completing this course, the viewer should be able to: