Documentation for Healthcare Providers: Ensuring Your Notes Speak for Your Actions

Documentation for Healthcare Providers:  Ensuring Your Notes Speak for Your Actions

Course Expiration Date:  2/28/22

 If you are purchasing this course the cost is $50.00.

Course Description:  This course is intended to assist all healthcare professionals with a review/refresher on the importance of proper, legally sound documentation.  The presentation reviews the SOAP method of documentation and how to appropriately document medication administration.

Target Audience:  Nurses, Medical Assistants, and other interested healthcare providers

Instructor:  Toni Malpass RN, MSN

Learning Outcomes:

At the end of this presentation, the learner will be able to:

    • Identify written communication as a tool useful for interdisciplinary communication.

    • Identify data that should be documented.

    • Describe what should NOT be documented.

    • Identify the principles of documentation.

    • Identify Federal, State, and regulatory standards that documentation must satisfy.

    • Identify the four parts of a SOAP note.

    • Utilize the SOAP format to completely and accurately document.

    • Identify the Medication Administration Cycle

    • List the 10 Rights of accurate medication administration

    • State the three medications checks and when they are performed

    • Apply the rights to a MAR, Pharmacy label, and controlled substance form

    • List the step for medication preparation, administration, and completion

    • Demonstrate how to correctly document on an MAR

    • Practice documenting medication and changes in note

    • Identify the areas on the MAR using a bar code device

Credit Statements:

Licensed Nurses:  Upstate AHEC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

 Upon successful completion of this program, attendees will receive 1.5 contact hours. 

Certified Medical Assistants: This program, #136081,  has been granted prior approval by the American Association of Medial Assistants (AAMA) for  1.5 A credit. Granting approval in no way constitutes endorsement by the AAMA of the program content of the program's sponsor.

AHEC Credit: This educational offering provides 0.15 CEUs (1.5 clock hour) by Upstate AHEC and meets SC AHEC Best Practice Standards.

Disclosure Statement: Upstate AHEC’s conflict of interest policy requires speaker(s), the planning committee members, and all others in a position to control this activity of this program to disclose any real or apparent commercial financial affiliations related to the content of this presentation or materials.

The speaker(s), the planning committee members, and all others in a position to control this activity have signed a vested interest form declaring no conflict of interest in this activity.

Provision of this education activity by Upstate AHEC does not imply endorsement by Upstate AHEC or ANCC of any commercial products displayed in conjunction with this activity.  

Credit Requirements: To receive CE credit for completing this online course you must complete 100% of the material, receive at least 80% passing grade on post-test and complete the evaluation.

Once you pass the post-test and complete the evaluation you will be able to print a certificate for verification of credit.

 The process for enrolling in AHECU courses has changed. Please go to www.upstateahec.org and click the blue AHECU/Distance Education block to register for online courses.  There is a tutorial on the web site if you need assistance with the registration process.