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Medical Record Documentation – 1 CE
At the conclusion of this continuing education activity, the participant will be able to:
- Define medical documentation and its role in facilitating safe and effective patient care, ensuring reimbursement for services provided, and serving as a legal record of the patient’s treatment.
- Identify and compare commonly used charting styles, including narrative charting, PMOR, charting by exception, and clinical pathways.
- Identify common concerns surrounding computerized charting and steps that health care professionals should take to mitigate these concerns.
- Recall best practices in legally defensible charting.
- Recall how the Health Insurance Portability and Accountability Act protects sensitive health information.
This nursing continuing professional development activity was approved by the Georgia Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.
AchieveCE is also an accredited provider by the Florida Board of Nursing (Provider #50-20641) and the California Board of Registered Nursing (CEP17265). This course is approved by CE Broker, with CE Broker No. 20-650652.
Level 2. Basic Application of Skills and Concepts
Financial Support Disclosure
This activity was developed by AchieveCE free of any commercial support.
Home Study Monograph
1.0 Contact Hour
Medical Record Documentation
Advanced Practice Registered Nurse
Certified Nursing Assistant
Licensed Practical Nurse
Mental Health Professional
Nursing Home Administrator
Contains case-based material
Dr. Patricia Dunn DNP, APRN, FNP-BC
Requirements for Credit
Participants must score a passing grade of 70% or higher on the activity post-test and complete an activity evaluation. There are no time limits and unlimited test-taking attempts. Credits will be reported automatically to CE Broker if your license information is entered properly in your profile.
PLEASE NOTE. AchieveCE does hold national accreditation from the Academy of General Dentistry. AchieveCE also is an approved provider of nursing CE from both the California Board of Nursing and the Florida Board of Nursing. For all other professions, this activity is only approved for Florida credit.
Windows 8.1, Windows 10
Mac OS X 10.1 or higher
iOS 10+, Android 4.3+
Google Chrome, Microsoft Edge, Mozilla Firefox
Adobe Acrobat Reader
Broadband Internet Connection:
T1, Hi-speed DSL or Cable
4G cellular connection
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