Observing, Reporting, and Documenting

Course Code: REL-PAC-0-OREDOC

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

Review

Verbal Reports

Close the Loop

Interact® Program

Documentation 

Electronic Medical Record

Incident Reports

What About Mrs. Gubbins?

Review

Summary

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: Direct Care Workers; in the following settings: Post-Acute Care.

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All courses offered by Relias Learning, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.

To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.

Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.