Documenting Care: The Charting Process Video (CE 1 hour)
Charting, the recording and documentation of a patient's condition, treatment and response to treatment, is one of the most basic nursing skills. Charting are fact-based reports with information presented in a clear and objective way. They must be accurate, legible, concise, continuous and complete. This program reviews the fundamental techniques used in accurate charting and discusses confidentiality issues related to charting, including the new HIPAA rules, and describes some of the legal aspects of charting.