Documentation is arguably one of the least favorite professional duties of any nurse. Whether you have been a nurse for many years or are fresh out of school, it is always good to review the basics of recording entries into a health record. This presentation will discuss the legal and functional requirements of documentation and describe ways to ensure documentation that is safe, legal, complete, and concise.

• Review required documentation practices
• Describe complete, concise nursing documentation
• List elements of safe and legal nursing documentation

Level: Basic