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Medical Record Documentation – 1 CE

Activity Overview

Learn about the proper medical documentation in this CE as an essential part of holding the care team accountable and ensuring the patient receives the best possible care. This course also fulfills Florida CNA's requirement on Medical Record Documentation.

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Learning Objectives

At the conclusion of this continuing education activity, the participant will be able to:

  1. 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.
  2. Identify and compare commonly used charting styles, including narrative charting, PMOR, charting by exception, and clinical pathways.
  3. Identify common concerns surrounding computerized charting and steps that health care professionals should take to mitigate these concerns.
  4. Recall best practices in legally defensible charting.
  5. Recall how the Health Insurance Portability and Accountability Act protects sensitive health information.

Accreditation Statement

AchieveCE is an approved provider of nursing continuing professional development by the Georgia Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. GNA Approved Provider Number is 4003268.

Start Date: 07/14/2022
Expiration Date: 07/14/2025

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.

Content Complexity

  Level 2. Basic Application of Skills and Concepts

Delivery Type

Home Study Monograph



1.0 Contact Hour


Medical Record Documentation

Target Audience

Advanced Practice Registered Nurse
Certified Nursing Assistant
Licensed Practical Nurse
Mental Health Professional
Nursing Home Administrator
Physical Therapist
Registered Nurse

Activity Type

Contains case-based material

Activity Number

Activity 40061


Provider No. 50-20641
CA BRN No. 2020138
CE Broker No. 20-650652
GNA Approved Provider Number is 4003268


Dr. Patricia Dunn DNP, APRN, FNP-BC



Financial Support Disclosure

This activity was developed by AchieveCE free of any commercial support.

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.

CE Broker Reporting

If you are licensed under a board supported by CE Broker, feel free to log into your CE Broker account to view your reported courses or to contact their support staff.

Hardware Requirements

Windows 8.1, Windows 10
Mac OS X 10.1 or higher
iOS 10+, Android 4.3+

Software Requirements

Google Chrome, Microsoft Edge, Mozilla Firefox
Adobe Acrobat Reader

Network Requirements

Broadband Internet Connection:
T1, Hi-speed DSL or Cable
4G cellular connection

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