Documentation Course Introduction

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Included In This Lesson

Outline

Overview

  1. Documentation can be hard!
    1. What is covered in the Documenation Course?
      1. Introduction to the electronic medical records (EMR)
      2. Basic daily charting
      3. Shift change and patient hand-off
      4. Documentation of
        1. Provider phone calls
        2. Escalation of chain of command
        3. Medication errors
      5. Legalities of charting

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Transcript

Hey guys!  Documentation is a huge part of our jobs as nurses!  In the next slide I wanted to give you a glimpse into the different types of lessons that we cover in the documentation course!

In the documentation course we will take you through an introduction to the electronic medical record also known as the EMR, daily charting in its basic form but also the key points involved in documenting provider phone calls.  We will also explain the importance of documenting at shift change. A very important lesson included in this course is the legalities of charting or in other words how we keep ourselves as nurses safe with our documentation. Finally, in the event of a medication error, we review what to chart and also in the event of the escalation of the chain of command.

 

We love you guys! Go out and be your best self today! And as always, Happy Nursing!

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When you start a FREE trial you gain access to the full outline as well as:

  • SIMCLEX (NCLEX Simulator)
  • 6,500+ Practice NCLEX Questions
  • 2,000+ HD Videos
  • 300+ Nursing Cheatsheets