Documentation - Medical Records

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 appropriate 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: 10/31/2024 | Program Review Date 10/30/2027

This program has been submitted for Continuing Education for 0.75 total participant hours from NAB/NCERS.
NAB Approval #20251030-0.75-A107928-DL Program Start Date: 10/31/2024 | Program Review Date 10/30/2025 

Call the HealthCap Education Coordinator at 734-996-2700 for further information.