Documentation for CNAs: Best Practices Update 2023 (0 NCPD)
Updated for 2023! High-quality, accurate, and complete documentation is the foundation to any direct care practice. Learn the essentials in this course.
Course curriculum
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1
About this Course: Start Here
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2
Introduction
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Introduction - [Title]
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Introduction - [Video]
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Introduction
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3
Four Reasons Why Documentation is Important
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Documentation: Why It's Important - [Video]
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Overview
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Four Reasons Why Documentation is Important
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1. Client Health and Welfare
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Client Health and Welfare, Cont.
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2. Medical Record-Keeping
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3. Legal
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4. Financial
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4
Documentation Errors
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Documentation Errors - [Title]
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Types of Documentation Errors
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Abbreviation and Handwriting Errors
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Failure to Correct Documentation Errors
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Lack of Documentation
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Subjective Documentation
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*Wrong Chart
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No Documentation
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Documenting at the Wrong Time
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5
Documenting--The Right Way
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Documenting the Right Way - [Title]
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Documenting the Right Way - [Video]
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Overview
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Accurate
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Objective
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Complete
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Timely
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6
Documentation and HIPAA
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Documentation and HIPAA - [Title]
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Documentation and HIPAA - [Video]
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HIPAA: Overview
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What is the HIPAA Privacy Rule?
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What is the HIPAA Security Rule?
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HIPAA, CNAs and Privacy and Security
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Privacy
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Security
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7
Documenting Activities of Daily Living
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Documenting Activities of Daily Living - [Title]
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Documenting Activities of Daily Living: Overview
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Activities of Daily Living
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Approved Codes for ADLs
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1. Bed Mobility
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2. Dressing
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3. Eating
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4. Locomotion on the Unit
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5. Locomotion Off the Unit
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6. Personal Hygiene
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7. Toilet Use
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8. Transfers
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9. Walk in the Corridor
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10. Walk in the Room
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8
Course Summary and Quiz
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Course Summary
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References
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Course Quiz
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Course Evaluation Instructions
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Evaluation: We value your feedback
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CMS Coding for Documentation Handout
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Instructor(s)
Rachel West MHA, MSN, RN
Director of Education
[email protected]
A nurse for more than 20 years with a passion for Education, Rachel is committed to creating the best education for nursing professionals. Rachel believes that education is the foundation for individuals to reach their personal and professional goals. She loves learning and finding ways to make courses interesting, relatable, and timely.
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