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Best Practices in Documentation for Rehab Providers
Documentation is a critical component of therapy services. Your documentation is used to communicate with other healthcare professionals, evaluate the effectiveness of treatment, and substantiate billing by justifying the care provided. Individuals who review your documentation in the medical record will never see the therapy sessions, so you have to “tell the story” by including the necessary components to justify services for reimbursement. This course covers general guidelines for documentation, components to improve documentation, and special considerations. Practical examples are provided to help you incorporate best practices into your documentation.
Identify five required components of therapy goals.
Determine at least three ways to improve documentation through the use of evidence-based practice and demonstration of skilled need and medical necessity.
Recall at least four documentation requirements across all settings.
SIADH Management
Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition that occurs when the body produces too much antidiuretic hormone (ADH), which causes fluid retention and electrolyte imbalance. SIADH can have various causes and manifestations and can lead to serious complications if not recognized and treated promptly. This course will provide you with the knowledge to thoroughly assess and manage patients with SIADH in the hospital setting.
Explain the pathophysiology, causes, and diagnosis of SIADH.
Identify the signs and symptoms of SIADH and potential complications.
Review common treatments and nursing interventions for patients with SIADH.
Acute Heart Failure
Heart failure (HF) treatment is costly and requires a multidisciplinary approach. Evidence-based treatment guidelines improve patient outcomes, and it is essential to become familiar with these guidelines to reduce patient mortality. Healthcare team members play a significant role in treating acute HF (AHF), helping to reduce the morbidity and mortality of the disease and decrease the use and costs associated with care. This course aims to educate nurses and nutrition and dietetics professionals in the acute care setting about evidence-based heart failure treatment guidelines.
Describe heart failure, including its classification systems, presentation, treatment, and evidence-based therapies.
Describe strategies for patient self-management.
Nursing Assessment of the Pediatric Patient
In this course, you will learn about pediatric anatomical and physiological differences, which will help you recognize normal variations throughout your assessment. Additionally, you will learn communication methods to help children feel more at ease during your assessment. Finally, you will understand essential warning signs that require immediate referral to additional medical professionals using the available resources and tools.
Choose at least three strategies to help ensure success during an exam of the infant, child, and adolescent. Identify the proper way to perform a pediatric head-to-toe assessment using appropriate resource tools. Recognize signs in the infant, child, and adolescent that are concerning.
Pediatric Patients and Concussion Management
Concussion is a form of mild traumatic brain injury that is common in children and adolescents. Despite increased awareness about the injury, concussion remains under-reported and under-diagnosed. Nurses and Radiology Technicians must be aware of the identification, diagnosis, and management of concussions in pediatric patients.
Identify signs and symptoms of concussions in pediatric patients.
Recognize the evaluation, diagnosis, and management of concussions in pediatric patients.
Recall the complications of concussions in pediatric patients.
Emergency Management of Abdominal Pain
Abdominal pain is the single most common ED complaint (up to 10% of visits) and is in the top four for emergency medicine litigation. Emergency providers must be proficient in diagnosing abdominal pain to provide excellent care to patients and reduce their risk of being named in litigation. This course will address abdominal pain diagnosis and treatment in the ED for the elderly, adults, children, and young women (of childbearing potential).
State the evaluation of abdominal pain in the elderly.
Recognize the approach to abdominal pain in the post-bariatric surgery patient.
Discuss the presentation of testicular torsion.
Describe the scoring systems for appendicitis in adults and children.
Assess the non-abdominal causes of abdominal pain.