/

/

Documentation Course Introduction

Documentation Course Introduction

You're watching a preview. 300,000+ students are watching the full lesson.

Master

Previous Lesson

Next Lesson

Included In This Lesson

Additional Lessons

NURSING.com students have a 99.25% NCLEX pass rate.

Outline

Overview

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

Unlock the Complete Study System

Used by 300,000+ nursing students. 99.25% NCLEX pass rate.

200% NCLEX Pass Guarantee.
No Contract. Cancel Anytime.

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 Faster with Full Video Transcripts

99.25% NCLEX Pass Rate vs 88.8% National Average

200% NCLEX Pass Guarantee.
No Contract. Cancel Anytime.

🎉 Special Offer 🎉

Nursing School Doesn't Have To Be So Hard

Go from discouraged and stressed to motivated and passionate

CM

Concepts Covered:

Study Plan Lessons

Age and Culturally Appropriate Health Assessment Techniques for Certified Perioperative Nurse (CNOR)

Care for Asian-Indian Patient Populations

Care for Hispanic Patient Populations

Care for Native American Patient Populations

Care of Vulnerable Populations

Caring for African Patient Populations

Child Abuse/Neglect – Warning Signs Nursing Mnemonic (CHILD ABUSE)

Communicable Diseases

Community Aggregates

Community Health Course Introduction

Community Health Education

Community Health Nursing Theories

Community Health Tool Nursing Mnemonic (MAP-IT)

Continuity of Care

Cultural Considerations (Interpretive Services, Privacy, Decision Making) for Certified Emergency Nursing (CEN)

Disasters & Bioterrorism

Disposal of Medical Waste

Environmental Cleaning (Spills, Room Turnover, Terminal Cleaning) for Certified Perioperative Nurse (CNOR)

Environmental Health

Environmental Health Assessment Nursing Mnemonic (I PREPARE)

Environmental Stewardship (Waste Minimization) for Certified Perioperative Nurse (CNOR)

Fire Safety 1 Nursing Mnemonic (PASS)

Fire Safety 2 Nursing Mnemonic (RACE)

Health Promotion & Disease Prevention

Health Promotion Assessments

Health Promotion Model

High Risk Behavior Nursing Mnemonic (HEADSS)

High-Risk Behaviors

Intro to Community Health

Levels of Prevention

Malnutrition (Failure to Thrive, Malabsorption Disorders) for Progressive Care Certified Nurse (PCCN)

Planning Community Health Interventions Nursing Mnemonic (PRECEDE-PROCEED)

Practice Settings

Program Planning

Technology & Informatics

ACLS (Advanced cardiac life support) Drugs

Advanced Cardiovascular Life Support (ACLS)

Brief CPR (Cardiopulmonary Resuscitation) Overview

CPR-BLS (Basic Life Support)

Life Support Review Course Introduction

Neonatal Resuscitation Program (NRP)

Pediatric Advanced Life Support (PALS)

54 Common Medication Prefixes and Suffixes

Alpha-fetoprotein (AFP) Lab Values

Carboxyhemoglobin Lab Values

Cardiac Terminology

Diagnostic Testing Course Introduction

Diagnostics Terminology

Digestive Terminology

Gamma Glutamyl Transferase (GGT) Lab Values

Growth Hormone (GH) Lab Values

Hematology Oncology & Immunology Terminology

Integumentary (Skin) Terminology

Mean Corpuscular Volume (MCV) Lab Values

Mean Platelet Volume (MPV) Lab Values

Medical Terminology Course Introduction

MedTerm Basic Word Structure

MedTerm Body as a Whole

MedTerm Prefixes

MedTerm Suffixes

Metabolic & Endocrine Terminology

Methemoglobin (MHGB) Lab Values

Musculoskeletal Terminology

Myoglobin (MB) Lab Values

Neuro Terminology

Pharmacology Terminology

Prealbumin (PAB) Lab Values

Procedural Terminology

Psychiatry Terminology

Reproductive Terminology

Respiratory Terminology

Sensory Terminology

Urinary Terminology

Day in the Life of a Community Health Nurse

Facilitation of Learning for Progressive Care Certified Nurse (PCCN)

Fire and Electrical Safety

Giving the Best Patient Education

Patient Education

Radiation Safety for Nurses

Response to Diversity for Progressive Care Certified Nurse (PCCN)

Accountability and Assistance for Personal Limitations for Certified Perioperative Nurse (CNOR)

Admissions, Discharges, and Transfers

Advance Directives

Advanced Directive and DNR Status Confirmation for Certified Perioperative Nurse (CNOR)

Advocacy & Moral Judgement for Progressive Care Certified Nurse (PCCN)

Advocating For Your Patient

Applying for Jobs

Barriers to Health Assessment

Being Successful in Orientation

Career Planning & Job Selection Course Introduction

Caring Licensed Practical Nurse Nursing Mnemonic (CLPN)

Caring Practices for Progressive Care Certified Nurse (PCCN)

Certified Nurse Midwife

Climbing the Clinical Ladder

Collaboration for Progressive Care Certified Nurse (PCCN)

Communicating with Family Members

Communicating with Other Departments

Communicating with Other Nurses

Communicating With Other nurses

Communicating with Patients

Communicating With Pharmacy, RT, OT, PT

Communicating with Providers

Communicating With Providers

Communicating with UAPs

Communication Course Introduction

Communication of Patient Outcomes (Continuum of Care) for Certified Perioperative Nurse (CNOR)

Confidence Building as a New Grad Nurse

Confidence in Communication

Confidence in Communication – Live Tutoring Archive

Conflict Management (Patient, Perioperative Team, Family) for Certified Perioperative Nurse (CNOR)

Day in the Life of a Community Health Nurse

Day in the Life of a Labor Nurse

Day in the Life of a Med-surg Nurse

Day in the Life of a Mental Health Nurse

Day in the Life of a NICU Nurse

Day in the Life of a Peds (Pediatric) Nurse

Day in the Life of a Postpartum Nurse

Day in the Life of an ICU (Intensive Care Unit) Nurse

Day in the Life of an Operating Room Nurse

Delegation and Personnel Management for Certified Perioperative Nurse (CNOR)

Delegation of Tasks to Assistive Personnel for Certified Emergency Nursing (CEN)

Documentation Basics

Documentation Course Introduction

Documentation Pro Tips

Documenting Escalation (Chain of Command)

Ethical and Professional Standards for Certified Perioperative Nurse (CNOR)

Facilitation of Learning for Progressive Care Certified Nurse (PCCN)

Fall and Injury Prevention

Finding Your First Nursing Job as a New Grad

Fire and Electrical Safety

First Year in Nursing Course Introduction

Function Within Scope of Practice for Certified Perioperative Nurse (CNOR)

Fundamentals Course Introduction

Giving Handoff Report

Giving the Best Patient Education

Handling Job Rejection

HCIR Management (Healthcare Industry Representative) for Certified Perioperative Nurse (CNOR)

Healthcare Team Member Supervision and Education for Certified Perioperative Nurse (CNOR)

How to Give a Perfect Nursing Report (plus report sheet)

How to Take Nursing Report

How to Write A Nursing Progress Note

ICU Nurse Report to Floor Nurses

Impaired or Disruptive Behavior Reporting (Interdisciplinary Healthcare Team) for Certified Perioperative Nurse (CNOR)

Implant Records and Tracking for Certified Perioperative Nurse (CNOR)

Interdisciplinary Healthcare Team Collaboration for Certified Perioperative Nurse (CNOR)

Interdisciplinary Team Member Functions for Certified Perioperative Nurse (CNOR)

Interdisciplinary Team Participation for Certified Perioperative Nurse (CNOR)

Interviewing with Behavioral Questions

Interviewing with Nurse Manager

Introduction to the Electronic Medical Record (EMR)

Invoicing Process

Joint Commission

Legal Aspects of Documentation

Legal Considerations

Legalities of Charting

License Maintenance

Live Bedside Report OB and PACU

Live Bedside Report Medsurg (Medical surgical)

MSN (Masters) vs. DNP (Doctorate)

NRSNG Live | From Student to Real Nurse

NRSNG Live | Avoiding Legal Issues as a Nurse

NRSNG Live | So You Want to be a Surgical Nurse?

NRSNG Live | The Successful State of Mind

Nurse-Patient Relationship

Nursing Care Delivery Models

Nursing Interviews & Resumes Course Introduction

Nursing Report & Communication Course Introduction

Nursing Skills (Clinical) Safety Video

Nursing Skills Course Introduction

OB (Labor) Nurse Report to OB (Postpartum) Nurses

Patient and Family Teaching (Per Procedure) for Certified Perioperative Nurse (CNOR)

Patient Communication Techniques for Certified Perioperative Nurse (CNOR)

Patient Confidentiality for Certified Perioperative Nurse (CNOR)

Patient Consent for Treatment for Certified Emergency Nursing (CEN)

Patient Education

Patient Privacy and Dignity Maintenance for Certified Perioperative Nurse (CNOR)

Patient Records and Care Documentation for Certified Perioperative Nurse (CNOR)

Patient Rights Advocacy for Certified Perioperative Nurse (CNOR)

Patient Satisfaction for Certified Emergency Nursing (CEN)

Patient Status Communication for Certified Perioperative Nurse (CNOR)

Patient Status Evaluation (Transfer of Care) for Certified Perioperative Nurse (CNOR)

Patients with Communication Difficulties

Precepting a New Nurse

Precepting a Student

Prioritizing Assessments

Professional Organization Participation for Certified Perioperative Nurse (CNOR)

Provider Phone Calls

Radiation Safety for Nurses

Report For Transferring To a Higher Level of Care

Response to Diversity for Progressive Care Certified Nurse (PCCN)

Resume and Cover Letter

Risk Management for Certified Emergency Nursing (CEN)

SBAR and How to Give Handoff Report like a BOSS – Live Tutoring Archive

SBAR Communication

SBAR Communication Nursing Mnemonic (SBAR)

SBAR Practice Scenarios

Shift change and Patient handoff

The Customer Voice

The Medical Team

The Nurse Routine

The Top 5 Things You Need To Know About Documentation 1 – Live Tutoring Archive

The Top 5 Things You Need To Know About Documentation 2 – Live Tutoring Archive

Therapeutic Communication

Time Management

Transfer of Care Documentation for Certified Perioperative Nurse (CNOR)

Transition To Practice

Transition to Practice Course Introduction

Trusting your Gut

Verbal Order Read-Back for Certified Perioperative Nurse (CNOR)

Visitor Supervision for Certified Perioperative Nurse (CNOR)

What Guides Nurses Practice

Why CEs (Continuing education) matter

Working night shift

Working with a Preceptor