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!
NCLEX 2 WEEKS
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
- Factors Influencing Community Health
- 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
- Substance Abuse Disorders
- Anxiety Disorders
- Eating Disorders
- Depressive Disorders
- Personality Disorders
- Psychotic Disorders
- Trauma-Stress Disorders
- Bipolar Disorders
- Developmental Considerations
- Concepts of Mental Health
- Health & Stress
- Psychological Emergencies
- Somatoform Disorders
- Pregnancy Risks
- Labor Complications
- Fetal Development
- Terminology
- Prenatal Concepts
- Newborn Care
- Labor and Delivery
- Postpartum Care
- Postpartum Complications
- Concepts of Population Health
- Community Health Overview
- Understanding Society
- Hematologic Disorders
- Cardiovascular Disorders
- Musculoskeletal Disorders
- Endocrine and Metabolic Disorders
- Oncologic Disorders
- Prioritization
- Adult
- Dosage Calculations
- Concepts of Pharmacology
- Adulthood Growth and Development
- Learning Pharmacology