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.

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.

In this course, you will learn to identify different depressive disorders, as well as the unique ways depression manifests in children and adolescents. Additionally, you will learn to recognize risk factors for both depression and suicidality in youth.  

An integrated care model treats the whole child by combining primary care and mental healthcare in one setting. Within this model, treatment providers understand how to screen for depression and suicidality in order to coordinate care. You will learn about specific instruments useful for detecting depression and suicidality among youth. An understanding of the root causes of depression will highlight the rationale for various treatment approaches. Lastly, you will be able to describe the best practices available to help children and adolescents manage depression.