Course Summary

Expiration Date: 09/24/2028

This learning activity, From Notes to Narratives: EBP in Documentation That Protects and Guides, explores the principles and practices of evidence-based healthcare documentation. Designed for clinicians across disciplines, the course provides a comprehensive review of how to create clear, complete, and legally sound documentation that supports safe, high-quality, and collaborative care. Participants will learn strategies to capture the essential elements of the patient encounter, effectively use direct quotes, document clinical reasoning, and navigate special scenarios, including telehealth, behavioral health, and patient refusals. The module also addresses documentation efficiency, the importance of inclusive language, and the role of clinical notes in minimizing liability and improving continuity of care.

Course Format

Homestudy

Course Syllabus

  • Introduction
    • The Purpose and Power of Documentation
    • Evidence-Based Documentation: Defining the Concept
    • Components of Thorough, Legally Sound Documentation
    • Minimizing Liability Through Documentation
    • Efficiency Without Sacrificing Quality
    • Continuity and Collaboration: Documentation as a Communication Tool
    • Documentation and Health Equity
    • Special Situations in Documentation
    • Mental Health and Substance Use
    • Key Takeaways

Authors

Sarah Schulze, MSN, APRN, CPNP

Sarah Schulze is a board certified pediatric nurse practitioner and professional medical content writer. She earned her BSN from Indiana State University and her MSN from University of Illinois at Chicago. In clinical practice as an RN and NP, she has experience in a variety of settings; including critical care, PACU, pediatrics, mental health, and lactation support. She currently owns and operates a private practice providing outpatient mental health services to children and adolescents. As a writer, she has developed content for many CEU courses, medical apps, health education curricula, NCLEX study materials, health blogs, and more.

William Cook, PhD

William Cook, Ph.D. is a licensed psychologist who worked for 15 years in private practice in Montana before leaving his practice to work full time as the Director of CE4Less. He earned his doctorate degree from Texas A&M University, and focused much of his psychology practice in the area of child and family counseling, as well as psychological testing. Dr. Cook likes new challenges, foreign traveling to Africa and areas of Europe and the near East, scuba diving, running, music, and spending time with his family.