DISCLOSURES 
For Activity Participants to review prior to start of this course.
 
Approval Statement
This continuing nursing education activity was approved by the Florida Board of Nursing, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. FBN: # 50-12820
 
Activity Purpose and/or Learning Outcomes
  1. The learner will be able to recall the care that nursing assistants and home health aides must document.
  2. The learner will be able to recall the observations that nursing assistants and home health aides must document.
  3. The learner will be able to identify some things that should be done in order to make sure that the records are treated as legal documents.
  4. The learner will be able to some things that should NOT be done in order to make sure that the records are treated as legal documents.
  5. The learner will be able to identify one example of writing right.
  6. The learner will be able to identify one example of what not to write.
  7. The learner will be able to identify at least 2 reasons why the clinical record is important.
  8. The learner will be able to identify at least 2 basic rules about documentation.
  9. The learner will be able to identify at least 5 documentation tips.
  10. The learner will have successfully completed this course upon receiving an end-of-course passing quiz score of 75% or higher
  11. At the end of this course, and upon successful completion, the learner will achieve two (2) contact hour(s) towards continuing credits and/or renewal of license.
  12. The learner will be awarded a certificate of attendance, upon successful completion.
  13. The learner will be afforded the opportunity to evaluate the course, via an evaluation form 
Successful Completion of this Continuing Nursing Education Activity
In order to successfully complete this activity and receive full contact-hour(s) credit for this CNE activity, you must:
a.     Enter your healthcare license number in the "License # section," so that your CE contact hours
        can be reported to the appropriate licensing board.
b.     Read the attached Online Study Material.
c.     Take the multiple choice quiz below the study material, consisting of 11 questions.
d.     Achieve a passing quiz score of 75% or higher
e.     Evaluate the course via the survey link at the bottom of the quiz.
f.      If you have any questions or concerns about this course, please send an email to
        [email protected]
 
Conflicts of Interest
There is no conflict of interest for any planner or presenter of this activity.

THIS COURSE IS FREE, you pay for the quiz only!
 

5 Sample Questions

Documentation in the medical records must be

  • A. Complete
  • B. Correct
  • C. Done on time
  • D. All of the above

Some of the care that nursing assistants and home health aides must document are

  • A. Baths, Showers, Oral care, Denture care, Foot care, Hair and nail care
  • B. Urinary catheter care, Back care, Turning and positioning, Meal intake
  • C. Fluid intake, Activities, like walking, Range of motion exercises if done
  • D. Warm soaks, Cold applications
  • E. All of the above

Some of the observations that nursing assistants and home health aides must document are

  • A. Level of consciousness, Orientation to time, place and person, Height, Weight
  • B. Urinary drainage bag output, Temperature, Pulse, Respiration rate, Blood pressure
  • C. Blood glucose readings, Color of the skin, Warmth and characteristics of skin
  • D. Things that the patient or resident says, Things that the patient or resident communicates
  • E. Behaviors, like anger and yelling
  • F. All of the above

Observations that nursing assistants and home health aides must document are, all things that you see, hear or feel, especially if it is not normal

  • A. True
  • B. False

Some things that you should do in order to make sure that you treat these records as legal documents are

  • A. Use blue or black ink unless you are using a computer or your hospital uses aspecial color ink for different shifts
  • B. Write so that it can be read clearly. There should be no sloppy writing
  • C. Date all of your notes
  • D. Write the time that you write your note
  • E. Sign your full name and title (CNA, HHA, etc)
  • F. Write only facts
  • G. Keep all medical records in a safe and secure place
  • H. Medical records are confidential. Do not tell anyone about what is in them unlessthey are taking care of the person
  • I. All of the above

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