Nursing Documentation 101

Most health care providers know that accurate documentation (also known as charting, recording and reporting) is an important component of their professional and legal responsibilities. Nursing organizations have standards of practice (or practice guidelines) and specific competencies that address quality documentation, not just "good charting".

There were two major reasons why Documentation was selected for development of an eLearning course. Firstly, the College of Licensed Practical Nurses of Alberta (CLPNA) surveyed members and found a high demand for more training in documentation. Secondly, many audits across health disciplines found that most documentation fails to meet professional and legal standards (Paans, Nieweg and Van der Schanns, 2010). The purpose of this course is to provide Licensed Practical Nurses (LPNs) the knowledge and skills to perform their documentation responsibilities to accepted professional and legal standards.

Nursing Documentation 101 consists of seven modules. The learning activities include narrated video presentations, module quizzes, reflective scenarios/case studies and learning games/simulations. To access a learning activity, simply click on the Link. After you have completed an activity, return to this page to proceed to the next activity. We strongly recommend that the activities be done in the order shown. However, you are free to select your own learning path. A final examination is included.

Although this course was designed for LPNs, the information will be of benefit to all health care providers who wish to improve their documentation skills.

Technology Note: All interactive components are in Flash, iPad, Android and HTML5 formats. Adobe Flash needs to be installed on your computer if you are using a modern browser. For best viewing on Apple's iPad, download and install the FREE iPad Player App from the iTunes Store. If you are using an Android tablet, download and install the FREE Android Player App from Google Play. Adobe Reader is required to view and print the PDF-format documents.


Module 1: Course Introduction and Overview

1.1 Video presentation – narrated with notes (7 slides)

1.2 Video player tutorial – a one-minute tour of how to navigate the player

1.3 Podcast – click to listen or right-click to download the audio file for use off-line (7:08 minutes - 7 MB)

1.4 Handout notes – a printable version of the slides and narration (PDF format)


Module 2: Importance of Accurate Documentation

2.1 Video presentation – narrated with notes (18 slides)

2.2 Podcast – click to listen, or right-click to download the audio file to listen off-line (19:40 minutes - 19 MB)

2.3 Handout notes – a printable version of the slides and narration for this module (PDF format)

2.4 Mod. 2 Quiz I – online, interactive quiz (20 questions selected randomly from a pool of 50 items)

2.5 Mod. 2 Quiz II – printable /PDF version of quiz with answer key (50 questions)


Module 3: Essential Elements of Accurate Documentation

3.1 Video presentations – narrated with notes

3.1.1 Video presentation – Part I (30 slides)

3.1.2 Video presentation – Part II (15 slides)

3.2 Podcasts – click to listen, or right-click to download the audio file to listen off-line

3.2.1 Podcast – Part I (18:21 minutes - 17 MB)

3.2.2 Podcast – Part II (16:39 minutes - 7 MB)

3.3 Handouts – printable / PDF versions of the slides and narration for this module (PDF format)

3.3.1 Handout notes – Part I

3.3.2 Handout notes – Part II

3.4 Mod. 3 Quiz I – online, interactive quiz (20 questions selected randomly from a pool of 62 items)

3.5 Mod. 3 Quiz II – printable / PDF version of quiz with answer key (63 questions)


Module 4: Legal Issues in Documentation

4.1 Video presentation – narrated with notes (19 slides)

4.2 Podcast – click to listen, or right-click to download the audio file to listen off-line (18:25 minutes - 17 MB)

4.3 Handout notes – a printable version of the slides and narration for this module (PDF format)

4.4 Mod. 4 Quiz I – online, interactive quiz (20 questions selected randomly from a pool of 30 items)

4.5 Mod. 4 Quiz II – printable / PDF version of quiz with answer key (30 questions)


Module 5: Applying Documentation Knowledge to Practice

5.1 Video presentations – narrated with notes

5.1.1 Video presentation – Part I (22 slides)

5.1.2 Video presentation – Part II (21 slides)

5.2 Podcasts – click to listen, or right-click to download the audio file to listen off-line

5.2.1 Podcast – Part I (15:08 minutes - 14 MB)

5.2.2 Podcast – Part II (11:05 minutes - 10 MB)

5.3 Handouts – printable / PDF versions of the slides and narration for this module (PDF format)

5.3.1 Handout notes – Part I

5.3.2 Handout notes – Part II

5.4 Mod. 5 Quiz I – online, interactive quiz (20 questions selected randomly from a pool of 60 items)

5.5 Mod. 5 Quiz II – printable / PDF version of quiz with answer key (60 questions)


Module 6: Electronic Documentation

6.1 Video presentation – narrated with notes (16 slides)

6.2 Podcast – click to listen, or right-click to download the audio file to listen off-line (15:50 minutes - 15 MB)

6.3 Handout notes – a printable version of the slides and narration for this module (PDF format)

6.4 Mod. 6 Quiz I – online, interactive quiz (20 questions selected randomly from a pool of 30 items)

6.5 Mod. 6 Quiz II – printable / PDF version of quiz with answer key (30 questions)


Module 7: Additional Exercises and Resources

7.1 Case Study 1: Acute Care – Post-Operative ---> ONLINE | PRINT (PDF format)

7.2 Case Study 2: Community / Home Care ---> ONLINE | PRINT (PDF format)

7.3 Case Study 3: Continuing / Long Term Care – Geriatrics ---> ONLINE | PRINT (PDF format)

7.4 Terminology Game – a fun way to test your knowledge of the terms related to accurate documentation (15 items randomly selected from a pool of 70 questions)

7.5 Documentation Course – the full-text print version of this Nursing Documentation 101 course (PDF format)

7.6 Final Course Examination I – online version (40 questions randomly selected from 140 items) with a 45 minute time limit (with printable Certificate*)

7.7 Final Course Examination II – online version (80 questions randomly selected from 140 items) with a 90 minute time limit (with printable Certificate*)

7.8 Documentation Attitude Checklist – a checklist on your attitudes towards documenting (PDF format)

7.9 Terms to Avoid in Documentation – a list you can print out and post (PDF format)

7.10 Documentation Principles – 12 principles you can print out for a handy reference (PDF format)

7.11 Word Crimes – a fun music video by "Weird Al" Yankovic about using proper grammar

7.12 Glossary of Terms (PDF format)

7.13 References (PDF format)

7.14 Legal and Credits (PDF format)


Course Evaluation

Nursing Documentation 101 Evaluation – Please complete this online survey after finishing this Course. Your feedback and comments will greatly assist CLPNA in developing and delivering effective, quality nursing educational resources.

* To print your Certificate, set your printer to Landscape mode. If Google Chrome does not show the Certificate graphics, click "cancel" and close the print window. Then click on Print Certificate icon again and it should work.