Documentation for CNAs: Best Practices Update 2023
Updated for 2023! High-quality, accurate, and complete documentation is the foundation to any direct care practice. Learn the essentials in this course.
Introduction - [Title]
Introduction - [Video]
Introduction
Documentation: Why It's Important - [Video]
Overview
Four Reasons Why Documentation is Important
1. Client Health and Welfare
Client Health and Welfare, Cont.
2. Medical Record-Keeping
3. Legal
4. Financial
Documentation Errors - [Title]
Types of Documentation Errors
Abbreviation and Handwriting Errors
Failure to Correct Documentation Errors
Lack of Documentation
Subjective Documentation
*Wrong Chart
No Documentation
Documenting at the Wrong Time
Documenting the Right Way - [Title]
Documenting the Right Way - [Video]
Overview
Accurate
Objective
Complete
Timely
Documentation and HIPAA - [Title]
Documentation and HIPAA - [Video]
HIPAA: Overview
What is the HIPAA Privacy Rule?
What is the HIPAA Security Rule?
HIPAA, CNAs and Privacy and Security
Privacy
Security
Documenting Activities of Daily Living - [Title]
Documenting Activities of Daily Living: Overview
Activities of Daily Living
Approved Codes for ADLs
1. Bed Mobility
2. Dressing
3. Eating
4. Locomotion on the Unit
5. Locomotion Off the Unit
6. Personal Hygiene
7. Toilet Use
8. Transfers
9. Walk in the Corridor
10. Walk in the Room
Course Summary
Course Quiz
Course Evaluation Instructions
Evaluation: We value your feedback
References
CMS Coding for Documentation Handout