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Perioperative Series: Communication in the OR
In the operating room, patient safety depends on high quality communication and shared knowledge among the surgical team. Several factors in this setting can contribute to communication failures like time constraints, shift changes, environmental barriers, the complex nature of surgical procedures, and clashing communication styles. All members of the surgical team must understand the risks to patient safety associated with communication failures, what information must be communicated and when, and how to use an assertive communication style.
The goal of this course is to equip nurses and CSTs with best practices for effectively communicating in the operating room.
Describe best practices for facilitating communication in the OR.
Identify four communication styles and which style is most effective for ensuring patient safety.
List common barriers to effective communication in the OR.
Reducing Medical Errors in the OR
The OR is a complex environment. Highly trained individuals interact in a specialized setting with sophisticated and technically complicated devices, instruments, and equipment. There are also substantial differences among team members related to education, experience, skill level, influence, and formal and informal power. This course will inform nurses and surgical technologists of the evidence-based steps to take to create a culture of safety in the OR.
Identify the communication processes that aid in reducing medical errors and review recommendations for the safe transfer of patient care information.
Name organizations that are helping to create a culture of patient safety and their recommendations to meet this goal.
Determine the components of a just culture that promote trust and accountability and recall a 10-step process for creating a culture of safety in the OR.
Perioperative Specimen Handling
Proper surgical specimen handling is essential for patient safety. This course covers best practices for intraoperative personnel to prepare, label, and transfer specimens accurately. Adhering to these protocols ensures that specimens are identified and handled appropriately, minimizing the risk of harm to the patient.
This course provides OR nurses and surgical technologists with knowledge of best practices for specimen handling.
Describe the considerations and methods of preparing specimens for various pathologic and examination types.
Recall care standards for the appropriate handling, labeling, and transportation of specimens.
Identify common mistakes made during specimen management and prevention methods to avoid these errors.
A Look at Malignant Hyperthermia
Malignant hyperthermia (MH) is a life-threatening syndrome associated with an anesthetic trigger. Awareness of MH by all perioperative team members, from those working in the preoperative holding area to those in the Post Anesthesia Care Unit (PACU), is important in preventing negative patient outcomes.
Define risk factors for MH and preventive measures for improving patient outcomes.
Identify the signs and symptoms of MH along with diagnostic and genetic considerations.
Describe the best practices for managing and treating MH.
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.
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.
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.