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Direct caregivers are the eyes and ears of the care team. You are the person who spends the most time with individuals while giving them care. To effectively follow their individual plans of care, you observe, report, and document. The correct documentation is vital to your organization's financial and legal health. This course gives you information on how and what to observe, report, and document. The goal of this course is to educate direct care workers in all post-acute care settings on observing, reporting, and documenting.
Course Code: REL-PAC-0-OREDOCKS
Hours: 1
Type: Online Course
Content Expiration Date: 12/31/2028
Learning Objectives:Identify at least two signs or symptoms that indicate a change in condition.Discuss at least three effective methods to report and document condition changes.
Outline:
Section 1: Introduction
About This Course
Learning Objectives
Section 2: The Basics of Observation
The Case of Mrs. Gubbins
The Nursing Process
Use Observation
Signs and Symptoms
Objective and Subjective Findings
Changes in Condition
Review
Summary
Section 3: Reporting and Documentation
What to Report
Basic Observations
More About Pain
Pressure-Related Skin Injury
The Dying Process
Observing for Functional Decline
When to Report
Verbal Reports
Close the Loop
Interact® Program
Documentation
Electronic Medical Record
Incident Reports
What About Mrs. Gubbins?
Section 4: Conclusion
Course Summary
Course Contributor
References
Subject Matter Expert: Edward Bartels, RN, BSN, MICN
Ed has 30 plus years of nursing experience with clinical roles in trauma, emergency, critical care, skilled nursing, behavioral health, occupational health, home care, and is a certified clinical nursing instructor in North Carolina. Ed served as Director of Nursing for rural emergency services and physician practices. Ed earned his Bachelor of Science in Nursing from the University of North Carolina, Greensboro. Ed retired from the U.S. Coast Guard with 34 years served.
Target Audience:The target audience for this course is: Administrators; in the following settings: Post-Acute Care.
Relias Learning will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Relias Learning has a grievance policy in place to facilitate reports of dissatisfaction. Relias Learning will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias Learning at support@reliaslearning.com.
Course Delivery Method and FormatAsynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.
Relias strives to measurably improve the lives of the most vulnerable members of society and those who care for them by providing online analytics, assessments and learning across healthcare. The product of a merger between Silverchair Learning, Essential Learning, and Care2Learn, Relias delivers a breadth and depth of content unrivaled by its competitors. We provide flexible e-Learning solutions to meet your needs: Relias Academy for individuals, Relias Learning Management System for organizations, Enterprise solutions for large organizations and partnerships. Relias Learning is based in Cary, North Carolina. For more information, visit www.reliaslearning.com.