Medical Record Documentation & Legal Information for Certified Nursing Assistants

Course Code: REL-SRC-0-MRDLICNA

Hours: 1

Type: Online Course

Content Expiration Date: 12/31/2025

Learning Objectives:
Identify the purpose of the medical record and documentation.
Explain guidelines regarding when and what to document.
Describe good documentation practices to avoid errors.
Identify legal standards that affect the certified nursing assistant.

Outline:
Section 1: Introduction A. About This Course B. Learning Objectives Section 2: The Medical Record and Documentation A. The Purpose B. Electronic Medical Records C. Importance of Documentation D. When to Document E. What to Document F. Review G. Summary Section 3: Documentation Best Practices A. Painting a Picture B. One Simple Rule C. Good Documentation D. Mistakes and Late Entries E. Objective vs. Subjective Data F. Documenting Refusals G. Change of Condition H. Incomplete Documentation I. Use of Inflammatory Language J. Documentation Examples K. Review L. Summary Section 4: Legal Standards A. Laws and Rules B. Regulation of CNA Practice C. Scope of Practice D. In-Service Requirements E. Competency F. Maintaining Certification G. CNA Reporting Requirements H. Policies and Procedures I. Review J. Summary Section 5: Conclusion A. Summary B. Course Contributors C. References D. Congratulations!

Instructor: Cheryl Swann, RN-BC, BSN, WCC, LNHA

Cheryl Swann, RN-BC, BSN, WCC, LNHA has worked in long-term care for 20 years. Mrs. Swann has worked in many positions including Director of Nursing, Medicare Nurse Coordinator and Nursing Home Administrator. Cheryl is certified in both Gerontological nursing and wound care. In the past, she has assisted in the operations of multiple nursing facilities, including staffing, payroll, public health concerns, family member issues, management of consultant relationships (e.g. pharmacy, dietary, etc.), and as an intermediary between long-term care facilities and doctors. Mrs. Swann worked closely with federal monitors and the Office of Inspector General in developing an effective Continuous Quality Improvement and compliance program in her organization. Mrs. Swann has presented nationally regarding effective Quality Assurance, Restraint Reduction, Wound Prevention, CMS Five Star Quality Rating System and Developing a Corporate Compliance Program. Her expertise includes staff training and development, Quality Assurance and Performance Improvement initiatives, and policy development. Disclosure: Cheryl Swann, RN-BC, BSN, WCC, LNHA has no Relevant Financial or Non-Financial Relationship with ineligible companies to disclose.

Target Audience:
The target audience for this course is: Entry level 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.