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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.
Overview of Medications for Opioid Use Disorder
The current opioid use epidemic has had devastating consequences for those impacted by it. Medication for opioid use disorder (MOUD) is an effective, yet underused, approach to the treatment of opioid use disorder. By taking this course, you will have information that you can share with your clients and their family members about what MOUD is, its risks and benefits, and the types of medications used in MOUD. 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 overview of what MOUD is, how it can help individuals with opioid use disorder (OUD), and the medications used by providers that treat OUD.
Describe how opioids affect the brain and can become habit-forming.
Discuss the role of medications to treat opioid use disorder.
List the medications typically prescribed to treat opioid use disorder and the side effects and risks associated.
Addressing Trauma and Stressor Related Disorders
About 70% of adults in the U.S. have experienced at least one traumatic event (Sidran Institute, 2018). Most overcome their trauma responses without formal intervention. Others, however, experience persistent symptoms that need formal intervention. The goal of this course is to provide addiction, behavioral health counseling, marriage and family therapists, nursing, psychology, and social work professionals in health and human services settings with information on how to assess and treat trauma- and stressor-related disorders.
Recognize common symptoms that individuals may have in response to experiencing trauma.
Identify at least three tools that can help screen and assess for trauma-related disorders.
Determine which interventions would be most relevant for someone with a trauma-related disorder.
Impact of Substance Use Disorders on Families and Approaches to Treatment
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 service settings with information about how substance use disorders can impact family systems and approaches to help the family system.
Identify how family dynamics impact the development of a substance use disorder.
Recognize how substance use impacts the family members of individuals with substance use disorders.
Indicate evidence-based interventions that you can use to successfully address the relationship between the dynamics of family systems and substance use.
Managing Peripheral Artery Disease
The goal of this course is to provide the clinician with up-to-date best practices for identifying and treating patients with PAD. It includes symptoms, complications, risk factors, and modifications of PAD. In addition, diagnostic tests, assessment, and treatment strategies will be discussed.
Identify risk factors and complications related to PAD.
Discuss two assessment findings and tools used to diagnose PAD.
Describe two disease management and education techniques for patients with PAD.
Managing Patients with Liver Disease and Hepatic Failure
Approximately 30 million Americans have some form of hepatic failure. There are 11,886 people in the U.S. on the transplant list waiting for a new liver (Health Resources & Services Administration, 2021). Hepatic failure is rated as one of the leading causes of death, yet we know much less about this condition compared to other chronic diseases. Clinicians should be familiar with signs of liver failure and related conditions, risk factors for the disease, and treatment strategies.
The purpose of this course is to educate healthcare professionals on the causes, complications, and characteristics of hepatic failure to better manage and care for this patient population.
Identify causes, symptoms, and complications of liver disease and hepatic failure.
Identify diagnostic, monitoring, evidence-based treatment, and management strategies for persons with liver disease.
Recognize symptoms, diagnosis, treatment, and prevention of hepatitis A, B, and C.
Common Substances and Treatment of Substance Use Disorders
People have used substances since ancient times. Sometimes substances were used as a medicine to treat an ailment, for recreation, or to support spiritual practices. The desire to find ways to feel or think differently is a normal part of the human experience. However, some people who use drugs develop patterns of compulsive use that are hard for them to control due to how the drug impacts their brain. They can experience harmful, even fatal, consequences. In 2019, the results from the National Survey on Drug Use and Health estimated that 20.4 million people, or 7.4% of the population of the U.S. had a substance use disorder (SAMHSA, 2020a). As behavioral health providers, we have opportunities in our interactions with clients to address thoughts, beliefs, and behaviors around substance use. We can support clients around learning about substances, the impact of substances, work to prevent or identify problematic use and substance use disorders, as well as offer information about treatment or provide treatment to clients.
Identify at least four types of substances used and how they affect the body.
Recognize aspects of problematic use and elements of the diagnosis of a substance use disorder.
Recall at least three evidence-based treatments of substance use disorders
Depression and Suicidality in Older Adults
Depression and suicide are among the top public health concerns facing older adult populations. Older adults encounter changes physically, cognitively, and psychosocially that often contribute to the onset of depression. Further, older adult populations have among the highest incident rates of suicide than any other age group, which makes appropriate diagnosis and treatment of depression in this population even more critical. This course will provide an overview of some physical, cognitive, and psychosocial factors that could be contributing to depression in an older adult, as well as important information on recognizing risk factors and warning signs of depression in this population. Additionally, information related to evidence-based treatment strategies for older adult populations will be discussed along with the importance of monitoring treatment adherence.
Recall common indicators of depression, as well as risk factors and warning signs for suicide in older adult populations.
Indicate strategies to use to assess depressive symptoms and risk of suicide among older adults.
Describe evidence-based interventions for adults with depressive symptoms or those at heightened risk for suicide.
The Grief Process for Health Professionals
Grief is a normal and natural response to loss. It is not a problem to be solved, but rather a way of coping. This course discusses the basics of the grief process, the different types of grief, and ways of expressing grief. It also discusses tools to help you stay present and resilient as a healthcare professional supporting individuals and families.
Apply at least two grief models to individual circumstances.
Define three types of grief and their contexts.
Recognize two gifts of grief that apply to the general population.
Boundaries in the Treatment Relationship
This course explains the concept of a professional therapeutic boundary and how it differs from a personal relationship. You will learn about the ethical role of the clinical practitioner in establishing appropriate roles and boundaries, the difference between boundary crossings and boundary violations, how to appropriately use social media and other technology, and how to recognize situations with high potential for harmful boundary violations. As you master these skills, you will become more effective in maintaining an appropriate relationship between you and your clients.
Recall the meaning of a therapeutic boundary and the difference between boundary crossings and boundary violations.
Indicate how to avoid the red flags of boundary violations.
Discuss current standards for use of social media and other technology pertaining to maintaining therapeutic boundaries.
HCAHPS: Patient Care Experience
Hospitals and providers currently receive reimbursement by meeting criteria established by the Centers for Medicare & Medicaid Services (CMS). Quality measures and length of stay data are measures that affect hospital reimbursement. Yet the patient’s experience of care also remains a key factor in hospital reimbursement models. CMS uses the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to measure the patient’s experience, and nursing care is one part of the survey. Hospitals that perform well on the HCAHPS ratings are more likely to receive better reimbursement and bonuses. Nurses impact hospital ratings and reimbursement by providing the patient with a positive care experience.
Describe the impact of patients’ perception of their care experience on hospital reimbursement.
Discuss HCAHPS survey questions about staff responsiveness and strategies for improving survey ratings for these items.
Discuss the HCAHPS survey questions about medications and strategies for improving survey ratings for these items.
Best Practices for Interviewing Patients
The patient interview is the most important part of your exam. Gaining the patient’s perspective and learning more about issues important to them can guide you in developing patient-specific care plans. This course will discuss how to conduct patient-centered interviews. You will learn interviewing methods to effectively elicit the important details about a patient's reason for presenting to the clinic. Information will also be presented on how to approach challenging situations that arise during patient encounters.
Recall at least four ways you can facilitate rapport, engage patients in effective interviews, and facilitate discussions that guide quality treatment for your patients.
Indicate at least three strategies you can use to overcome common challenges that arise when interviewing patients.
Implementing a Quality Improvement System
While most health centers have some quality improvement (QI) functions established, many have not implemented a comprehensive, organization-wide QI program. Improving patient care and outcomes is the primary goal of QI programs. There are also financial benefits to providing quality care, especially as our healthcare system, including the Centers for Medicare and Medicaid Services (CMS), moves towards a “pay for performance” model (NEJM Catalyst, 2018b). This course will explain a comprehensive approach to implementing QI systems. You will learn about the essential elements of a QI program, including principles, program infrastructure, and process components. You will also learn how you can put the Model for Improvement QI methodology into action. Finally, you will learn how to identify quality-related problems using proactive and reactive strategies.
Recall the key components of a successful quality improvement program. Describe models and national initiatives for quality improvement and how they can benefit individuals receiving care from your organization. Indicate at least three specific actions you can implement in your setting to improve the quality of care provided.
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.
Integration of Primary and Behavioral Healthcare
You will learn about the costs, benefits, and goals of integrated care systems. As there are numerous challenges to integrating care, you will become aware of some of these key challenges, and familiar with particular characteristics of well-functioning integrated care systems. Finally, you will learn a variety of ways that behavioral healthcare professionals, including you, can function effectively in an integrated care environment.
Recall the different levels of integrated care and types of integrated care settings.
Indicate at least three tools or interventions you can use to facilitate an integrated approach to care delivery.
EMTALA Requirements
The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted to prevent patient dumping by hospitals seeking to avoid unrecoverable costs of care for patients without insurance or the ability to pay for medical services. Language within the statute has led to inconsistencies in how it has been interpreted. Patient dumping and inappropriate medical screening examinations (MSEs) are the most common reasons for EMTALA violations (Ladd & Gupta, 2021). This course will describe how key terms are currently interpreted and how they apply to hospitals with a dedicated emergency department (ED). In addition, learners will have an opportunity to review cases where EMTALA violations were alleged and judgments applied by the courts.
Define key terms and requirements associated with EMTALA.
Describe how EMTALA applies to certain situations.