Documentation Fundamentals
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The Documentation Fundamentals series focuses on core medical record standards and real-world documentation challenges that impact compliance, survey outcomes, and liability exposure.
Each session is designed to be practical, concise, and immediately applicable across roles and care settings.
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Contains 6 Component(s), Includes Credits
The clinical aspect of care is often the focus of documentation, every member of the interdisciplinary team who has direct contact with the resident is responsible for documenting the care and/or services they provide.
The primary reason for the clinical record is to provide information to support quality care and services delivered to a resident. To achieve this goal, it is important to have interdisciplinary, open communication including resident behaviors, change in condition, and care provided. Although the clinical aspect of care is often the focus of documentation, every member of the interdisciplinary team who has direct contact with the resident is responsible for documenting the care and/or services they provide. This program was developed to assist your team in maintaining the medical records for each resident.
Objectives:
- Identify recommended language to be used in the medical record
- Identify the importance of timely, accurate documentation
- Identify the risks associated with the use of unaccepted abbreviations
Attendees will be awarded 0.5 ANCC contact hours for completing the course/webinar.
Program Start Date: 10/31/2025 | Program Review Date 10/30/2028
This program has been submitted for Continuing Education for 0.75 total participant hours from NAB/NCERS.
NAB Approval # 20261030-0.75-A116042-DL
Program Start Date: 10/31/2025 | Program Review Date 10/30/2026
Call the HealthCap Education Coordinator at 734-996-2700 for further information.
Jill Harding, RN, LNHA, CLNC
Risk Manager
HealthCap
Jill Harding has served our long-term care industry for over two decades in various roles throughout skilled nursing facilities. She has been a Registered Nurse since 2011 and a Licensed Nursing Home Administrator since 2014 having served in both For-Profit and County Owned Medical Care Facility.
As a Certified Legal Nurse Consultant (CLNC), she serves her passion from both sides of our industry from a regulatory and healthcare legal perspective to help provide the best outcomes. She specializes in medical malpractice defense cases, utilizing decades of first hand clinical, administrative and regulatory experience.
In addition to her CLNC services, Jill serves her love of continuing to work alongside our healthcare facilities as a Risk Management/Loss Control Consultant and Healthcare Consultant & Educator. Providing support and education to homes in areas of operations, regulatory compliance and risk management services.
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Contains 4 Component(s)
This program was developed to assist you in identifying ways to improve documentation that meets best practices because hindsight is not 20/20!
Hindsight is 20/20, you have heard that phrase in the past! When it comes to resident care, hindsight is 0/0! Identifying subtle changes in condition through observation and assessment may assist in decreasing the risk of negative outcomes. This approach includes a thorough assessment process, care plan development, supervision, and identifying subtle changes in condition to assist in decreasing the risk of negative outcomes. This program was developed to assist you in identifying ways to improve documentation that meets best practices because hindsight is not 20/20!
Objectives:
- Describe why good documentation is important
- Identify examples of poor documentation
- Identify issues with inaccurate documentation
Jill Harding, RN, LNHA, CLNC
Risk Manager
HealthCap
Jill Harding has served our long-term care industry for over two decades in various roles throughout skilled nursing facilities. She has been a Registered Nurse since 2011 and a Licensed Nursing Home Administrator since 2014 having served in both For-Profit and County Owned Medical Care Facility.
As a Certified Legal Nurse Consultant (CLNC), she serves her passion from both sides of our industry from a regulatory and healthcare legal perspective to help provide the best outcomes. She specializes in medical malpractice defense cases, utilizing decades of first hand clinical, administrative and regulatory experience.
In addition to her CLNC services, Jill serves her love of continuing to work alongside our healthcare facilities as a Risk Management/Loss Control Consultant and Healthcare Consultant & Educator. Providing support and education to homes in areas of operations, regulatory compliance and risk management services.
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Contains 6 Component(s), Includes Credits
Residents are very dynamic, even minor changes can affect their behaviors; however, major changes increase the risk of a negative outcome.
Residents are very dynamic, even minor changes can affect their behaviors; however, major changes increase the risk of a negative outcome. A minor change in medication dosage may have a negative effect on a resident as well as unmanaged pain, leading to a change in behavior. Consideration should also be given to but not limited to transfer trauma, change in life situation, change in family dynamics/situation/role reversal. This program was developed to assist you, the caregiver, on best practices for documenting changes in resident behaviors and identifying the root cause of the change.
Objectives
- Identify the components of a thorough physical examination
- State three reasons that a resident may experience a change in behaviors
- Identify ways to document changes in behaviors
Attendees will be awarded 0.5 ANCC contact hours for completing the course/webinar.
Program Start Date: 10/31/2025 | Program Review Date 10/30/2028
This program has been submitted for Continuing Education for 0.75 total participant hours from NAB/NCERS.
NAB Approval # 20261030-0.75-A116043-DL
Program Start Date: 10/31/2025 | Program Review Date 10/30/2026
Call the HealthCap Education Coordinator at 734-996-2700 for further information.
Jill Harding, RN, LNHA, CLNC
Risk Manager
HealthCap
Jill Harding has served our long-term care industry for over two decades in various roles throughout skilled nursing facilities. She has been a Registered Nurse since 2011 and a Licensed Nursing Home Administrator since 2014 having served in both For-Profit and County Owned Medical Care Facility.
As a Certified Legal Nurse Consultant (CLNC), she serves her passion from both sides of our industry from a regulatory and healthcare legal perspective to help provide the best outcomes. She specializes in medical malpractice defense cases, utilizing decades of first hand clinical, administrative and regulatory experience.
In addition to her CLNC services, Jill serves her love of continuing to work alongside our healthcare facilities as a Risk Management/Loss Control Consultant and Healthcare Consultant & Educator. Providing support and education to homes in areas of operations, regulatory compliance and risk management services.
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Contains 5 Component(s), Includes Credits
This program we developed to assist caregivers, medication techs, and licensed nurses in documenting based on best practices.
Anticoagulants are a family of medications that stop your blood from clotting too easily. They can break down existing clots or prevent clots from forming in the first place. These medications can help stop life-threatening conditions like strokes, heart attacks and pulmonary embolisms, all of which can occur because of a blood clot. Residents who take anticoagulants have a high risk of internal bleeding, especially in their brain, from falls and injuries. This program was developed to assist you in understanding how anticoagulants work and being alert to signs and symptoms of a life-threatening event.
Objectives
- Describe what an anticoagulation medication is
- Describe what an anticoagulation medication is used for
- Identify the risks associated with the use of anticoagulation medications
- Identify why residents receiving anticoagulation medications are at higher risk for injuries related to falls
Attendees will be awarded 0.50 ANCC contact hours for completing the course/webinar.
Program Start Date: 02/26/2025 | Program Review Date 02/25/2028
Call the HealthCap Education Coordinator at 734-996-2700 for further information.Angie Szumlinski, LNHA, RN, GERO-BC, RAC-CT, BS
Director of Risk Management
HealthCap Risk Management Services
Ms. Szumlinski is a nationally-recognized leader in long-term care, with a wealth of experience in virtually every operational and clinical aspect of the industry. She has experience as an Owner/Provider, Administrator, Director of Nursing, Corporate Quality Assurance Coordinator, and independent consultant. As a nationally recognized presenter for health care associations on current trends and best practices in the long-term care industry, Ms. Szumlinski is the author of hundreds of best-practice bulletins, in-service modules, and has hosted hundreds of risk management seminars across the country. Respected for success in assisting facilities in achieving and maintaining regulatory compliance, Ms. Szumlinski served two terms as an Associate Board Member for NCAL, is a member of the AHCA Survey/Regulatory Committee, NCAL's Emergency Preparedness and Life Safety Committee, PALTmed Infection Control Committee and served as a team leader for the AHCA/NCAL Quality Award program for 8 years. Ms. Szumlinski is the Nurse Planner for HealthCap Risk Management’s American Nursing Credentialing Center’s (ANCC) accredited education program.
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Contains 5 Component(s), Includes Credits
This program we developed to assist caregivers, medication techs, and licensed nurses in documenting based on best practices.
Diabetes is a serious disease that affects many older adults. An estimated 33% of adults aged 65 or older have diabetes. Older adults with diabetes are at higher risk of developing complications such as hypoglycemia, kidney failure, and heart disease. This program was developed to assist you in identifying signs and symptoms of hypo/hyperglycemia and how to manage the resident’s care.
Objectives:
- Identify risk factors associated with diabetes
- Define what diabetes is and its impact on the body
- Identify what and when to document
Attendees will be awarded 0.50 ANCC contact hours for completing the course/webinar.
Program Start Date: 02/26/2025 | Program Review Date 02/25/2028
Call the HealthCap Education Coordinator at 734-996-2700 for further information.Angie Szumlinski, LNHA, RN, GERO-BC, RAC-CT, BS
Director of Risk Management
HealthCap Risk Management Services
Ms. Szumlinski is a nationally-recognized leader in long-term care, with a wealth of experience in virtually every operational and clinical aspect of the industry. She has experience as an Owner/Provider, Administrator, Director of Nursing, Corporate Quality Assurance Coordinator, and independent consultant. As a nationally recognized presenter for health care associations on current trends and best practices in the long-term care industry, Ms. Szumlinski is the author of hundreds of best-practice bulletins, in-service modules, and has hosted hundreds of risk management seminars across the country. Respected for success in assisting facilities in achieving and maintaining regulatory compliance, Ms. Szumlinski served two terms as an Associate Board Member for NCAL, is a member of the AHCA Survey/Regulatory Committee, NCAL's Emergency Preparedness and Life Safety Committee, PALTmed Infection Control Committee and served as a team leader for the AHCA/NCAL Quality Award program for 8 years. Ms. Szumlinski is the Nurse Planner for HealthCap Risk Management’s American Nursing Credentialing Center’s (ANCC) accredited education program.
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Contains 5 Component(s), Includes Credits
This program we developed to assist caregivers, medication techs, and licensed nurses in documenting based on best practices.
Documentation in assisted living is more than just a paperwork requirement. It is a powerful tool that can help address challenges, implement solutions, and achieve positive outcomes. By adopting advanced technologies and robust documentation practices, assisted living facilities can provide residents with the highest standard of care. Implementing Electronic Health Records (EHRs) can help consolidate medical records, care plans, and daily observations. This program we developed to assist caregivers, medication techs, and licensed nurses in documenting based on best practices.
Objectives:
- Identify the difference between objective and subjective documentation
- State the importance of documenting as an interdisciplinary team
- State the importance of using approved abbreviations in the medical record
Attendees will be awarded 0.50 ANCC contact hours for completing the course/webinar.
Program Start Date: 01/10/2025 | Program Review Date 01/09/2028
Call the HealthCap Education Coordinator at 734-996-2700 for further information.Amy Leep, RN, BSN, NHA, RAC-CT
Risk Manager
HealthCap Risk Management Services
Ms. Leep is a seasoned professional with nearly 30 years of experience in the long-term care industry, specializing in both for-profit and non-profit sectors. Her extensive background includes key leadership roles such as Director of Nursing, Administrator, and Independent Consultant. With expertise in clinical and operational management, policy and procedure development, and quality assurance, she is committed to elevating standards in long-term care.
In 2021, she founded Comply LLC, an Independent Consulting and Education business dedicated to assisting Assisted and Senior Living operators with regulatory compliance and operational management. Ms. Leep holds certifications in MDS Coordination and Infection Control, and she serves as a CPR, Nurse Aide, and Medication Aide trainer.
An engaging speaker, she has presented at numerous seminars and podcasts, sharing her insights and knowledge with industry peers. With a passion for improving care delivery and supporting professional growth, Ms. Leep continues to make a significant impact in the field of long-term care
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Contains 4 Component(s)
This program was developed to assist you in identifying those residents at highest risk for dehydration based on their comorbidities and to identify the early signs of dehydration to prevent negative outcomes.
Older people who live in skilled nursing facilities have a higher risk for chronic dehydration because they tend to drink less. Other risk factors among people in this group include: diabetes, kidney impairment, cognitive impairment or dementia, trouble swallowing and disabilities that limit their ability to feed themselves. This program was developed to assist you in identifying those residents at highest risk for dehydration based on their comorbidities and to identify the early signs of dehydration to prevent negative outcomes.
Objectives
- Define dehydration
- Identify the impact dehydration can have on the elderly
- Identify the signs and symptoms of early dehydration
- Define what treatment modalities will assist in preventing or treating dehydration
Jill Harding, RN, LNHA, CLNC
Risk Manager
HealthCap
Jill Harding has served our long-term care industry for over two decades in various roles throughout skilled nursing facilities. She has been a Registered Nurse since 2011 and a Licensed Nursing Home Administrator since 2014 having served in both For-Profit and County Owned Medical Care Facility.
As a Certified Legal Nurse Consultant (CLNC), she serves her passion from both sides of our industry from a regulatory and healthcare legal perspective to help provide the best outcomes. She specializes in medical malpractice defense cases, utilizing decades of first hand clinical, administrative and regulatory experience.
In addition to her CLNC services, Jill serves her love of continuing to work alongside our healthcare facilities as a Risk Management/Loss Control Consultant and Healthcare Consultant & Educator. Providing support and education to homes in areas of operations, regulatory compliance and risk management services.