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