Medical Record Documentation and Legal Information for CNAs

Course Code: REL-PAC-0-MRDLIC

Hours: 1

Type: Online Course

Content Expiration Date: 12/31/2029

Learning Objectives:
Discuss the purpose of the medical record and documentation.
Identify at least two documentation practices used to avoid errors.
Explain the legal standards that affect the certified nursing assistant.

Outline:
Section 1: Medical Record and Documentation

The Purpose

Technology and Documentation

Why? When? What?

Taking Fred’s Vital Signs

Key Takeaways

Section 2: Best Practices for Documenting

How to Document

Objective or Subjective

Review

Change of Condition

Documentation Gone Bad

Review

Key Takeaways

Section 3: Legal Standards

Health and Safety

CNA Practice

Education and Training

Review

Key Takeaways

Section 4: Conclusion

Course Summary

Course Contributor

Resource

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: Direct Care Workers; in the following settings: Post-Acute Care.

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.

Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.