Charting the Course: The Essentials of Medical Record Documentation
Master the fundamentals of accurate medical record documentation. This 1-hour course highlights best practices to improve clinical communication, enhance patient safety, and support regulatory compliance. CE credit is automatically reported to CE Broker for hassle-free renewal.
About this course
Charting the Course: The Essentials of Medical Record Documentation is a 1-hour continuing education (CE) course designed for healthcare professionals who want to strengthen their clinical documentation practices. Accurate, complete, and timely documentation is essential to ensure patient safety, maintain legal compliance, and support seamless care coordination across providers and settings.
This course highlights the vital role that documentation plays in healthcare quality, from improving patient outcomes to serving as a legal and professional safeguard. Participants will learn best practices for creating clear, objective, and defensible medical records that reflect the care provided and support clinical decision-making.
The course also explores documentation pitfalls that commonly lead to miscommunication, delays in care, and legal liability. Real-world examples and practical strategies are used to help participants apply principles to their daily workflow.
Key topics include:
Core elements of effective medical documentation
Charting methods and documentation formats
Legal and regulatory standards for healthcare records
Common documentation errors and how to avoid them
Tips to enhance clarity, accuracy, and completeness in records
This course is ideal for nurses, physicians, pharmacists, and allied health professionals seeking to refine their documentation skills, protect themselves legally, and contribute to safer, more efficient patient care.
Course Accreditation
Instructors
Patricia Dunn DNP, APRN, FNP-BC is a Nurse Practitioner with over 20 years of experience as an Advanced Practice Nurse and 20 years as a Registered Nurse. She has served as an APRN for Florida Pain Institute, Heart Rhythm Associates of Brevard, House Calls of Central Florida. She earned her Doctorate of Nursing Practice from Walden University, Minneapolis.
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I am always interested in continuing education in the areas of health, wellness, nutrition and mental health. Your course was well written, well organized and helpful in meeting state licensure requirements.
Verified reviewVery well written, easy to digest, time efficient, and straight to the point. Thank you!
Verified reviewI appreciate the convenience of the course being online and accessible through my phone and that it directly reports to CEBroker to support mandated education requirements.
Verified reviewI really loved this information. I was hospitalized last year for almost a month and I noticed multiple medical errors (not being hooked up to my IV multiple times, given wrong medication which caused my sodium to be very low, etc.) which lengthened my stay. I can now define those exact errors and better understand what happened to me. I hate that these medical errors are so common and I appreciate how well laid out your breakdown and categorization of them was.
Verified reviewI am always looking for concise ,thorough, and up to date continuing education, and this course provided exactly what I was looking for. Thank you
Verified reviewEnjoyed this course! It squarely met my license renewal requirement as a physician. It was well-written, and an altogether enjoyable read.
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