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!
Study Guide pre LPN-RN
Concepts Covered:
- Cardiac Disorders
- Cardiovascular
- Emergency Care of the Cardiac Patient
- Shock
- Shock
- Disorders of the Posterior Pituitary Gland
- Endocrine
- Disorders of Pancreas
- Disorders of the Thyroid & Parathyroid Glands
- Gastrointestinal
- Upper GI Disorders
- Liver & Gallbladder Disorders
- Lower GI Disorders
- Central Nervous System Disorders – Brain
- Neurological
- Noninfectious Respiratory Disorder
- Respiratory
- Hematologic Disorders
- Delegation
- Perioperative Nursing Roles
- Acute & Chronic Renal Disorders
- Respiratory Emergencies
- Disorders of the Adrenal Gland
- Documentation and Communication
- Preoperative Nursing
- Legal and Ethical Issues
- Immunological Disorders
- Oncology Disorders
- Female Reproductive Disorders
- Cognitive Disorders
- Musculoskeletal Trauma
- Intraoperative Nursing
- Medication Administration
- Vascular Disorders
- Renal Disorders
- Male Reproductive Disorders
- Sexually Transmitted Infections
- Infectious Respiratory Disorder
- Gastrointestinal Disorders
- Newborn Complications
- Peripheral Nervous System Disorders
- Studying
- Integumentary Disorders
- Communication
- Microbiology
- Emergency Care of the Trauma Patient
- Urinary Disorders
- Integumentary Disorders
- Musculoskeletal Disorders
- Circulatory System
- EENT Disorders
- Postoperative Nursing
- Neurological Emergencies
- Disorders of Thermoregulation
- Neurological Trauma
- Basics of NCLEX
- Fundamentals of Emergency Nursing
- Integumentary Important Points
- Multisystem
- Test Taking Strategies
- Tissues and Glands
- Urinary System
- Emergency Care of the Neurological Patient
- Neurologic and Cognitive Disorders
- Central Nervous System Disorders – Spinal Cord
- Renal and Urinary Disorders
- Nervous System
- Respiratory Disorders
- Respiratory System
- Infectious Disease Disorders
- EENT Disorders
- Emergency Care of the Respiratory Patient
- Health & Stress
- Skeletal System
- Endocrine System
- Hematologic System
- Digestive System
- Reproductive System
- Endocrine and Metabolic Disorders
- Muscular System
- Sensory System
- Basics of Human Biology
- Adult
- Anxiety Disorders
- Depressive Disorders
- Dosage Calculations
- Understanding Society
- Concepts of Pharmacology
- Newborn Care
- Adulthood Growth and Development
- Pregnancy Risks
- Postpartum Complications
- Substance Abuse Disorders
- Bipolar Disorders
- Learning Pharmacology
- Psychotic Disorders
- Prenatal Concepts
- Prefixes
- Suffixes
- Fetal Development
- Terminology
- Proteins
- Statistics
- Med Term Basic
- Med Term Whole
- Labor Complications
- Labor and Delivery
- Postpartum Care
- Hematologic Disorders
- Cardiovascular Disorders
- Musculoskeletal Disorders
- Oncologic Disorders
- Eating Disorders
- Personality Disorders
- Trauma-Stress Disorders
- Developmental Considerations
- Concepts of Mental Health
- Psychological Emergencies
- Somatoform Disorders
- Prioritization
- Factors Influencing Community Health
- Community Health Overview