Documentation Course Introduction
Included In This Lesson
Outline
Overview
- Documentation can be hard!
- What is covered in the Documenation Course?
- Introduction to the electronic medical records (EMR)
- Basic daily charting
- Shift change and patient hand-off
- Documentation of
- Provider phone calls
- Escalation of chain of command
- Medication errors
- Legalities of charting
- What is covered in the Documenation Course?
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!
aja -year off
Concepts Covered:
- Basics of Sociology
- Statistics
- Fundamentals of Emergency Nursing
- Factors Influencing Community Health
- Concepts of Population Health
- Studying
- Community Health Overview
- Developmental Considerations
- Microbiology
- Communication
- Legal and Ethical Issues
- Understanding Society
- Circulatory System
- Emergency Care of the Cardiac Patient
- Emergency Care of the Trauma Patient
- Emergency Care of the Neurological Patient
- Neurological
- Multisystem
- Medication Administration
- Emergency Care of the Respiratory Patient
- Health & Stress
- Delegation
- Cardiovascular
- Labor Complications
- Pregnancy Risks
- Newborn Complications
- Fetal Development
- Terminology
- Prenatal Concepts
- Newborn Care
- Labor and Delivery
- Postpartum Care
- Postpartum Complications
- Gastrointestinal
- Behavior
- Concepts of Mental Health
- Emotions and Motivation
- Growth & Development
- Intelligence and Language
- Psychological Disorders
- State of Consciousness
- Test Taking Strategies
- Note Taking
- Basics of NCLEX
- Substance Abuse Disorders
- Urinary System
- Nervous System
- Respiratory System
- Basics of Human Biology
- Concepts of Pharmacology
- Gastrointestinal Disorders
- Depressive Disorders
- Prioritization
- Anxiety Disorders
- Cognitive Disorders
- Eating Disorders
- Personality Disorders
- Psychotic Disorders
- Trauma-Stress Disorders
- Bipolar Disorders
- Psychological Emergencies
- Somatoform Disorders
- Peripheral Nervous System Disorders
- Cardiac Disorders
- Musculoskeletal Disorders
- Noninfectious Respiratory Disorder
- Central Nervous System Disorders – Brain
- Respiratory Emergencies
- Perioperative Nursing Roles
- Integumentary Disorders
- Disorders of Pancreas
- Neurological Emergencies
- Intraoperative Nursing
- Central Nervous System Disorders – Spinal Cord
- Shock
- Preoperative Nursing
- Vascular Disorders
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- Neurological Trauma
- Musculoskeletal Trauma
- EENT Disorders
- Prefixes
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- Proteins
- Med Term Basic
- Med Term Whole
- Basics of Mathematics
- Adult
- Basic
- Neonatal
- Pediatric
- Respiratory Disorders
- Writing
- EENT Disorders
- Acute & Chronic Renal Disorders
- Documentation and Communication
- Urinary Disorders
- Hematologic Disorders
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- Endocrine System
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- Adulthood Growth and Development
- Prenatal and Neonatal Growth and Development
- Childhood Growth and Development
- Developmental Theories
- Disorders of the Adrenal Gland
- Disorders of the Thyroid & Parathyroid Glands
- Upper GI Disorders
- Disorders of the Posterior Pituitary Gland
- Female Reproductive Disorders
- Infectious Respiratory Disorder
- Learning Pharmacology
- Tissues and Glands
- Respiratory
- Digestive System