Nurses are required to document everything of significance that happens on their shift. This can be a straightforward process, but there are often challenges. There are all kinds of scenarios that present documentation difficulties. Patients may refuse treatment or want to leave the hospital against medical advice. Your unit may be understaffed, and you want to document a complaint. The computer system can go down and you have to document on paper. Or maybe your documentation just takes too long, and you are wondering how to document faster. This course reviews strategies for documentation in challenging situations and how to document more efficiently.

To know documentation principles and to apply them in daily practice are musts for every nurse. These are essential to protect patients and to safeguard every nurse’s license. Documentation is the foundational proof that care was provided to a patient. Requirements and methods of documenting are ever-changing amongst a variety of documentation modalities. Although nurses sometimes view documentation as a process that takes precious time away from direct patient care, it is one of the most critical skills they perform. In fact, appropriate and effective documentation is at the core of nursing practice.

The goal of this course is to provide nurses working in acute care settings with information about the value of laws and standards governing nursing documentation, legal basics for appropriate documentation, and provide awareness of documentation practices that can lead to legal issues.

Documenting care is just as important as providing care. This course discusses the purpose of the medical record and documentation. It also describes documentation practices and legal standards that affect the certified nursing assistant.
This course provides direct care workers in post-acute care education on documentation and legal aspects of care.

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.

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.

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.

As a professional nurse, you are expected to be familiar with many aspects of care. You are not exempt from malpractice or negligence claims because you were following orders. You are responsible for assessing, planning, implementing, and evaluating appropriate nursing care. What you document can and does reflect the care provided and the outcomes of that care. Documentation that is factual, complete, timely, and detailed is required. In this course, you will learn about concepts and rules regarding documentation in the medical record. Legal aspects to be aware of while practicing will also be discussed. The goal of this course is to educate nursing professionals in post-acute care settings about the legal implications of documentation.

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. 

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).