Documentation Toolkit for the Nurse Leader

AAPACN’s Documentation Toolkit for the Nurse Leader is a comprehensive, practical resource designed to help nurse leaders systematically improve the quality, consistency, and effectiveness of nursing documentation in post-acute and long-term care settings. Grounded in the four pillars of documentation, the toolkit provides education, documentation guides, audit tools, and application ideas. It supports regulatory compliance, risk reduction, effective communication, and accurate reflection of resident care, while also helping nurse leaders create workflows and learning environments that enable nurses to document timely, accurate, and person-centered care. AAPACN nurse experts designed the Documentation Toolkit for the Nurse Leader to be practical, applicable, and include fun educational activities for the nursing team.

• Use the 40 educational tools, which includes 19 different documentation guides covering clinical conditions and special situations, to enhance the nursing team’s ability to apply the nursing process and document accordingly
• Create workflows that enable consistent and comprehensive documentation
• Apply the nursing process and documentation relationship as a framework to develop documentation skill competency
• Define documentation standards as they relate to the Medicare Benefit Policy Manual
• Understand the relationship and processes between documentation and the MDS
• Learn documentation protocols that can mitigate risks of litigation
• Find out how surveyors utilize documentation to investigate compliance