Da
Dawn O.Nutritionist
Verified review
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.
Charting the Course: The Essentials of Medical Record Documentation
1 hour
Credits / Contact Hours
$10
This course included in
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Course applies toward state CE requirements and hours needed for your FL RN license renewal. View Terms
This course is guaranteed to meet or exceed your expectations for convenience and quality. View Terms
Very well written, easy to digest, time efficient, and straight to the point. Thank you!
Da
Dawn O.
Verified review
I appreciate the convenience of the course being online and accessible through my phone and that it directly reports to support mandated education requirements.
Pr
Priya M.
Verified review
The course was well organized and helpful in meeting state licensure requirements. I found the content to be very informative and practical.
Cr
Cristina G.
Verified review
Course
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.
Course
Charting the Course: The Essentials of Medical Record Documentation
1.0 Credit / CME HourText
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.
Nationally & state accredited
Course Features
Instant certificates
All required courses
7-day live chat & phone support
Auto reporting to
Unlimited course attempts
What you'll learn
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.
Course description
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 content
Introduction
What is Medical Documentation
Communication of Information
Charting Styles
Narrative-Chronological
Problem-oriented Medical Records
SOAP (Subjective, Objective, Assessment, Plan)
SOAPIER (Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision)
DAR(P) (Data, Assessment or Action, Response, Plan):
Charting by Exception
Clinical Pathways
Computerized Records
Legally Defensible Charting
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Conclusion
Course details
CE Broker ID20-650652
Activity TypeKnowledge-based
Activity FormatEnduring
Explore more continuing education topics
Instructor
Patricia DunnDNP, APRN, FNP-BC
Patricia DunnDNP, APRN, FNP-BC
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.
Ideal CE course for these professions
This continuing education course is especially relevant for these healthcare professions, but other professionals may also benefit
Licensed Mental Health CounselorSocial Worker InternLicensed Social WorkerLicensed Clinical Social WorkerCertified Master Social WorkerLicensed Independent Marriage and Family TherapistLicensed Independent Social WorkerRegistered Nurse PractitionerAdvanced Practice NursesPhysical Therapy AssistantLicensed Practical NurseLicensed Independent Clinical Social WorkerRegistered NurseLong-Term Care Facility AdministratorsPhysical TherapistLicensed Mental Health Counselor InternLicensed Masters Social WorkerMaster's Social WorkNursing Home AdministratorLicensed Certified Social WorkerLicensed Baccalaureate Social WorkerLicensed Marriage and Family Therapist InternLicensed Independent Social Worker DualCertified Nursing AssistantRegistered Social Worker AssistantLicensed Marriage and Family TherapistLicensed Marriage and Family Therapist SupervisorBachelor's Social WorkerLicensed Independent Social Worker Advanced PracticeLicensed Graduate Social WorkerLicensed Independent Social Worker Clinical PracticeLicensed Massage Therapist
Accreditations
AchieveCE (50-20641) is a Florida Physical Therapy Association (FPTA) approved course provider. We are also a Rule/Statute Approved Provider by the AZ, GA, MS, ND, SC, and TN state boards through reciprocity with the FPTA.
Frequently asked questions
How many CE credits does this course provide?
This course, "Charting the Course: The Essentials of Medical Record Documentation", provides 1 contact hour of continuing education credit upon successful completion.
Is this course accredited?
Yes, this course is accredited by Physical Therapy, Long-Term Care Facility Administrators, Massage Therapy, Nursing, Mental Health. AchieveCE is an approved provider of continuing education for healthcare professionals.
Which professions is this course approved for?
This course is especially relevant for: Licensed Mental Health Counselor, Social Worker Intern, Licensed Social Worker, Licensed Clinical Social Worker, Certified Master Social Worker, Licensed Independent Marriage and Family Therapist, Licensed Independent Social Worker, Registered Nurse Practitioner, Advanced Practice Nurses, Physical Therapy Assistant, Licensed Practical Nurse, Licensed Independent Clinical Social Worker, Registered Nurse, Long-Term Care Facility Administrators, Physical Therapist, Licensed Mental Health Counselor Intern, Licensed Masters Social Worker, Master's Social Work, Nursing Home Administrator, Licensed Certified Social Worker, Licensed Baccalaureate Social Worker, Licensed Marriage and Family Therapist Intern, Licensed Independent Social Worker Dual, Certified Nursing Assistant, Registered Social Worker Assistant, Licensed Marriage and Family Therapist, Licensed Marriage and Family Therapist Supervisor, Bachelor's Social Worker, Licensed Independent Social Worker Advanced Practice, Licensed Graduate Social Worker, Licensed Independent Social Worker Clinical Practice, Licensed Massage Therapist. Other healthcare professionals may also benefit from this continuing education content.
How do I report my CE credits after completing this course?
Your credits are automatically and instantly reported to CE Broker upon successful completion. No manual reporting is required on your part.
Will I receive a certificate of completion?
Yes, you will receive a certificate of completion immediately after finishing the course and passing the assessment. The certificate can be downloaded and printed directly from your account.
What is your refund policy?
We offer a 30-day money-back guarantee. If you are not satisfied with your purchase, you can request a full refund within 30 days of purchase.
How long do I have to complete this course?
You have unlimited time to complete the course at your own pace. Once purchased, the course is available in your account until its expiration date. You can pause and resume at any time.
Most helpful reviews
Real reviews, real resultsDa
Dawn O.Nutritionist
Verified reviewI 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.
Pr
Priya M.Occupational Therapist
Verified reviewVery well written, easy to digest, time efficient, and straight to the point. Thank you!
Cr
Cristina GRegistered Nurse
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.
Al
Allison B.Nurse Practitioner
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 reviewPr
Priya M.Occupational Therapist
Verified reviewVery well written, easy to digest, time efficient, and straight to the point. Thank you!
Cr
Cristina GRegistered Nurse
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.
Al
Allison B.Nurse Practitioner
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.
Buy with confidence with money back guarantees
This course is guaranteed to meet or exceed your expectations for convenience and quality. View Terms
Includes all state CE requirements and hours needed for your license renewal. View Terms
Requirements & disclosures
Financial Disclosures
This activity was developed by AchieveCE free of any commercial support. The following individuals have indicated that they have no financial relationships with an ineligible company that may impact upon this activity:
Patricia Dunn, DNP, APRN, FNP-BC - Nurse Planner and, Content Expert and Faculty
Gracielle Tubera - Content Reviewer
Luke Porter – Content Reviewer
Dianne Arroyo - Activity Publisher
Passing Grade
Participants must achieve a passing score on the activity post-test, which may be 70% or 80%, depending on the course. They must also 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 correctly in your profile.
Hardware Requirements
Windows 8.1, Windows 10, Mac OS X 10.1+, 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 Cable4G cellular connection
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