Effective Documentation

Proper documentation is essential for avoiding claims and ensuring the integrity of the documentation. Claims and disputes often hinge on the accuracy and completeness of records. It also enables teams to track issues and coordinate resident care. It is important when documenting that policies and regulations are adhered to, that documentation is accurate and up-to-date, abbreviations are avoided when possible and documentation is done in real time. Documentation should include clinical information such as assessments, responses to medications, resident education and diagnostic tests. By adhering to these guidelines, nurses can enhance their documentation practices and reduce the risk of legal claims.  

Objectives

• Identify common errors in documentation that increase risk 

• Identify the disciplines responsible for documenting in the medical record 

• State why simplicity encourages compliance 

Attendees will be awarded 1.0 ANCC contact hours for completing the course/webinar.
Program Start Date: 3/13/2026 | Program Review Date: 3/12/2029

This program has been submitted for Continuing Education for 1.0 total participant hours from NAB/NCERS. 

NAB Approval #20270312-1-A119687-DL

Program Start Date: 3/13/2026 | Program Review Date 3/12/2027

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