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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.
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.
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.
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.
Ethical and Legal Considerations for Telehealth
This course will offer a blend of ethical and legal information, clinical vignettes, and strategies that can later be applied in therapeutic settings. The content of this course includes information about informed consent, confidentiality, privacy, boundaries, mandatory reporting, and rules for sharing information. The course assumes the learner has a basic understanding of telehealth technologies and formats. To learn more, you can search the Relias library for additional courses related to telehealth.
The goal of this course is to provide addictions professionals, behavioral health counselors, marriage and family therapists, psychologists, social workers, and nurses in health and human services settings with strategies and information for competent and ethical telehealth practice.
Name the key sources of information that inform ethical and legal telehealth service delivery.
Identify at least two competencies required for delivering telehealth services.
List specific steps for ensuring confidentiality, informed consent, appropriate boundaries, mandated reporting, and sharing of information within telehealth service delivery.
Describe common ethical missteps and legal problems that arise with telehealth service delivery and how providers can avoid these issues.
Stroke Care: From Onset to Rehab
This course provides a comprehensive understanding of stroke care from onset to rehab. Details of stroke care in the acute care setting and rehabilitation for stroke are reviewed. Stroke prevention strategies are explained.
Apply knowledge of assessment, diagnosis, and treatment for stroke in the hyperacute and acute phase.
Identify secondary prevention strategies, including lifestyle changes and drug therapies.
Recall interventions for rehabilitation from stroke in the acute and post-acute setting.
Understanding Domestic and Intimate Partner Violence
This course provides information about the dynamics of intimate partner violence, or IPV, risk factors, safety concerns, screening measures, and how staff can be the most helpful in these situations.
The goal of this course is to help administrative staff, general staff, and direct care staff in all healthcare settings gain a basic understanding of the dynamics of intimate partner violence.
Define domestic and intimate partner violence.
Describe risk factors for intimate partner homicide, including guns and strangulation.
Identify at least two screening measures used to identify persons who have experienced IPV.
Assessing and Treating Opioid Use Disorder
In Session: Practicing Clinical Skills to Prevent Suicide in Adults
The goal of this course is to provide addictions, behavioral health counseling, marriage and family therapy, nursing, psychology, and social work professionals in health and human services settings with an opportunity to apply your existing knowledge to assess and intervene with an at-risk adult.
Identify risk factors and warning signs for suicidality in adults.
Indicate the appropriate steps to assess an individual’s level of suicide risk.
State the essential interventions to implement based on the level of identified risk.
Medical Approaches to Identifying and Treating Alcohol Use Disorder
Alcohol use disorder is a primary health condition that interacts with and complicates many other health problems and psychiatric disorders. Unfortunately, only a small number of people with alcohol use disorder receive appropriate treatment for substance use issues. The incorporation of screening for alcohol use disorders in a general medical setting can significantly increase the number of individuals with alcohol use disorders who are identified and treated. The U.S. Food and Drug Administration (FDA) has approved 4 medications to treat alcohol use disorder, making treatment in primary care and other general medical settings a viable alternative to specialty care. This course will give you valuable information about these medications as well as several medications used off-label.
Identify strategies you can use to more effectively identify alcohol use disorder in a medical setting.
Recall factors that indicate someone may be a good candidate for medication-assisted treatment of alcohol use disorder as well as factors that suggest this approach is contraindicated.
Discuss the common medications used to treat alcohol use disorder, their benefits, and potential side effects.