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Writing Incident Reports
Writing incident reports is an important part of providing direct support services. Your reports help the person's support team respond effectively to their needs and keep them safe in the future.
The goal of this course is to teach DSPs in IDD settings the key elements of an incident report, why they are important, and how to write them effectively.
Recall the purpose and key elements of an incident report.
Identify strategies used to document and report incidents effectively.
Differentiate between effective and ineffective incident reports.
Nursing Documentation: Challenging Situations
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.
Apply documentation strategies for challenging patient care and coworker situations.
Apply documentation strategies for challenging situations related to hospital systems.
Identify ways to save time when documenting.
Nursing Documentation: Legal Aspects
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.
Describe four characteristics of legally-credible charting.
Discuss the legal definition of nursing negligence.
Describe two charting practices that can lead to legal issues.
Medical Record Documentation and Legal Information for CNAs
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.
Discuss the purpose of the medical record and documentation.
Identify at least two documentation practices used to avoid errors.
Explain the legal standards that affect the certified nursing assistant.
Controlled Substances: Chronic Pain Management
Chronic pain is a common condition for which healthcare providers often prescribe controlled substances, such as opioids. Prescription opioids can alleviate pain in certain patients, but the risk of misuse, abuse, and overdose means providers need to evaluate the risks and benefits for each patient. This course will educate healthcare providers on the role of prescription opioids along with other therapies for chronic pain, using recommendations from current national guidelines.
The goal of this course is to educate healthcare providers on methods for the safe and responsible use of controlled substances for the management of chronic pain.
Indicate treatment options for patients with chronic pain.
Identify safe strategies to initiate or change opioid analgesics.
Name patient factors and characteristics that can make prescribing opioids unsafe.
Culture and Pain Management: Cultural Competence
Health inequities in pain management are prevalent across different healthcare settings. The cultural, ethnic, and social differences influence patients’ and providers’ perceptions and responses to pain. Several studies report higher incidences of pain, disability, and suffering in women and people of color compared to non-Hispanic White people. This course covers influential sociocultural factors grouped into the patient, the provider, and systemic factors. This course helps healthcare professionals become familiar with cultural differences associated with pain perceptions and management. Pain variables such as culture, religion or ethnicity are not part of standardized pain scales. Healthcare workers need to provide culturally competent care to their patients by asking about specific practices, beliefs, and values regarding pain that impacts the patient’s quality of life.
The goal of this course is to provide nurses, physicians, and social workers with an overview of cultural sensitivity in the management of pain.
Identify cultural factors influencing the patient’s perception and expression of pain.
Recall strategies for reducing barriers in pain assessment and promoting management decisions to respond to a patient’s pain in a culturally sensitive manner.
Opioid Prescribing, Chronic Pain, and Opioid Use Disorder
The emphasis on pain management to improve quality of life and function has contributed to a significant increase in opioid prescriptions. As such, there has been a concurrent increase in risk of misuse and abuse. While opioids are highly effective for pain relief, closer attention to the risk versus benefit analysis has led to guidelines that prefer nonpharmacologic and nonopioid pharmacologic therapy over opioids, especially for chronic pain. Clinicians must carefully monitor the patient and be alert for signs that risks outweigh benefits of opioids. This course will address issues related to opioid prescribing, chronic pain, and opioid use disorder.
Discuss considerations and guidelines for prescribing controlled substances.
Describe patient evaluation and education for a safe and effective pain treatment plan.
Opioid Use During Pregnancy
Americans are using opioids at an alarming rate, whether through prescriptions or illegal means. Parallel to this problem is the use of opioids during pregnancy.
The goal for this course is to present RNs, PAs, physicians, and entry-level drug and alcohol counselors in inpatient or outpatient settings with best practices for identifying and managing pregnant women who are using opioids.
Recognize the risks and complications related to opioid use disorder during pregnancy.
Identify evidence-based treatment recommendations for opioid use disorder during pregnancy.
Documentation: The Legal Side
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.
Discuss malpractice, negligence, and compensatory and punitive damages as they relate to healthcare. Explain four intentional torts that a healthcare professional may be held liable for. Describe four documentation techniques to use to avoid legal issues.
Managing Pain Amid the Opioid Crisis
Pain management in the emergency department relies heavily on the use of opioid analgesics, which generates risk for patients to develop long term opioid use or an opioid use disorder. Multimodal analgesia can improve the patient experience and reduce the risks of opioid use if emergency providers approach pain with a more critical mindset.This activity is designed to help emergency providers improve management of pain while decreasing patient exposure to opioids. It is also designed to help providers navigate how to manage patients with opioid use disorder.
Identify different types of pain (acute pain, chronic pain, chronic cancer pain, and social pain) and the neurobiological origins of this pain.
Describe the risks associated with opioid analgesia.
Demonstrate knowledge of multimodal analgesia regimens to manage pain in the emergency department.
Describe the characteristics of opioid use disorder and the effectiveness of medication assisted therapy.