Description
CNAs and HHAs face daily challenges with documentation. Along with daily care tasks, it is essential to complete medical notes. Otherwise, medication errors, missed treatments, and serious legal issues might arise.
This course teaches the five rights of medical documentation in home health care. It covers what Florida CNAs and HHAs can legally do under state and federal law. Learners practice ways to protect patient information. The course also explains how to fix errors and report changes to nursing supervisors.
Objectives
Objective 1: Master the five rights of medical documentation. Know what must be documented.
Learn: Learn the five rights of documentation in home care. Follow the right time, right patient, right facts, right format, and proper signature.
Act: Write notes right after giving care. Use facts you observe, not opinions.
Objective 2: Work within the legal scope of practice for a Florida CNA/HHA.
Learn: Recognize what CNAs and HHAs can do legally. Remember that Florida law requires CNAs and HHAs to work under the supervision of a nurse and follow the care plan exactly as written.
Act: Identify situations that need the attention of the nurse. Spot the difference between objective and subjective notes.
Objective 3: Honor the privacy of clients in home care. Follow the federal law for protected health information.
Learn: Know basic rules for safe spaces. Keep personal health information private.
Act: Take care of private information. Cover the client during personal care. Discuss sensitive matters directly with the client.
Objective 4: Update and correct documentation promptly. Report changes to the nurse.
Learn: Identify the correct way to fix errors in medical records.
Act: Follow agency rules for correcting mistakes. Report changes to your supervisor.
Certificate
By completing/passing this course, you will attain the certificate Continua Learning Course Certificate
Learning credits
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