Charting the Course: The Essentials of Medical Record Documentation - Continuing Education Course

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.

Fulfils state requirements
included in AchieveCE+

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.

Ce Broker Id:20-650652
Activity Type:Knowledge-based
Activity Format:Enduring
Target Audience:
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
Nursing Home Administrator
Licensed Masters Social Worker
Master's Social Work
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
Category:Medical / Surgical, Communication

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Course Accreditation

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.

  • Arizona State Board of Physical Therapy

  • Arkansas State Board of Physical Therapy

  • Florida Board of Physical Therapy Practice

  • Georgia State Board of Physical Therapy

  • Michigan Board of Physical Therapy

  • Mississippi State Board of Physical Therapy

  • North Dakota Board of Physical Therapy

  • Oklahoma Board of Medical Licensure and Supervision - Physical Therapy

  • South Carolina Board of Physical Therapy

  • Tennessee Board of Physical Therapy

Instructors

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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.

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Real reviews, real results

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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.

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Dawn O.Nutritionist
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Very well written, easy to digest, time efficient, and straight to the point. Thank you!

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Priya M.Occupational Therapist
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I 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.

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Cristina GRegistered Nurse
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I 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.

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Allison B.Nurse Practitioner
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I am always looking for concise ,thorough, and up to date continuing education, and this course provided exactly what I was looking for. Thank you

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Ronald H.Dentist
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Enjoyed 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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Meghan L.Physician
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$ 7.00
1 hour

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