High-quality nursing assessments and documentation skills can be difficult to maintain, especially when using electronic health records. This presentation is a refresher on what is important to document in nursing encounters, knowing you might be reading it as the only source of information three years later in court, and will include a discussion of licensure and clinical responsibility.

Educational Objectives

• Discuss the objectives of nursing documentation
• Describe appropriate documentation based on the totality of the circumstances
• Differentiate between the types of documentation required for various nursing encounters

Level Basic