Documentation Course Introduction

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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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Concepts Covered:

  • Documentation and Communication
  • Legal and Ethical Issues
  • Medication Administration
  • Communication
  • Postoperative Nursing
  • Intraoperative Nursing
  • Preoperative Nursing
  • Vascular Disorders
  • Oncology Disorders
  • Musculoskeletal Trauma
  • Neurological Emergencies
  • Cardiac Disorders
  • Respiratory Disorders
  • Renal Disorders
  • Noninfectious Respiratory Disorder
  • Labor Complications
  • Eating Disorders
  • Disorders of Pancreas
  • Substance Abuse Disorders
  • Hematologic Disorders
  • Pregnancy Risks

Study Plan Lessons

How to Write A Nursing Progress Note
Documenting Escalation (Chain of Command)
Medication Errors
Legalities of Charting
Introduction to the Electronic Medical Record (EMR)
Provider Phone Calls
Shift change and Patient handoff
Daily Charting
Documentation Course Introduction
Post-Anesthesia Recovery
Postoperative (Postop) Complications
Discharge (DC) Teaching After Surgery
Local Anesthesia
Moderate Sedation
Malignant Hyperthermia
Preoperative (Preop)Assessment
Preoperative (Preop) Education
Preoperative (Preop) Nursing Priorities
General Anesthesia
Ultrasound
Biopsy
Informed Consent
Magnetic Resonance Imaging (MRI)
Cerebral Angiography
Cardiovascular Angiography
Echocardiogram (Cardiac Echo)
X-Ray (Xray)
Computed Tomography (CT)
ABGs Nursing Normal Lab Values
Metabolic Acidosis (interpretation and nursing diagnosis)
Respiratory Alkalosis
Respiratory Acidosis (interpretation and nursing interventions)
ABG (Arterial Blood Gas) Interpretation-The Basics
Isotonic Solutions (IV solutions)
Base Excess & Deficit
Metabolic Alkalosis
Sodium-Na (Hypernatremia, Hyponatremia)
Potassium-K (Hyperkalemia, Hypokalemia)
Hypertonic Solutions (IV solutions)
Hypotonic Solutions (IV solutions)
Chloride-Cl (Hyperchloremia, Hypochloremia)
Hemoglobin (Hbg) Lab Values
Red Blood Cell (RBC) Lab Values
Platelets (PLT) Lab Values
White Blood Cell (WBC) Lab Values
Hematocrit (Hct) Lab Values
Ammonia (NH3) Lab Values
Cholesterol (Chol) Lab Values
Albumin Lab Values
Coagulation Studies (PT, PTT, INR)
Urinalysis (UA)
Creatinine (Cr) Lab Values
Blood Urea Nitrogen (BUN) Lab Values
Hemoglobin A1c (HbA1C)
Glucose Lab Values