Observing, Reporting, and Documenting
Hours: 1.00
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.
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.
Florida Board of Nursing - Certified Nursing Assistants
This is not an accredited course for professional license renewal. Florida CNAs may use this inservice toward meeting their annual inservice requirement.
This activity is approved for 1.0000 contact hours.
Washington State Department of Social and Health Services (ALL Direct Care Workers)
Relias Learning, LLC is approved as a Curriculum Developer by the Washington State Department of Social and Health Services. This activity is approved for 1.0000 contact hours for all WA State Direct Care Workers. Training Provider Code: WA0624. CE Approval Code: CO2236788
California Department of Social Services Residential Care Facilities for the Elderly
Relias, LLC is approved by the California Department of Social Services as a Continuing Education Training Program Vendor to provide Continuing Education training courses to administrators of residential care facilities for the elderly.
Vendor/Provider # 2000224-740-2;
Approval # 224-0147-36474.
This activity is approved by the California Department of Social Services for 1.0000 contact hours.
California Department of Social Services Adult Residential Facilities
Relias, LLC is approved by the California Department of Social Services as a Continuing Education Program Vendor to provide Continuing Education training courses to administrators of Adult Residential Facilities.
Vendor/Provider # : 2000224-735-2
Approval # 224-0147-36473
This activity is approved by the California Department of Social Services for 1.0000 contact hours.
California Department of Public Health (CNA)
Relias, LLC is an approved provider of continuing education by the California Department of Public Health, Provider # NAC7001.
The certificate must be retained by the licensee for a period of four (4) years after the course is completed.
This learning activity meets the definition of *** ONLINE *** CEUs. This activity is approved for 1.00 contact hours.
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
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. Disclosure: Edward Bartels, RN, BSN, MICN has no Relevant Financial or Non-Financial Relationship with ineligible companies to disclose.
The target audience for this course is: Direct Care Workers; in the following settings: Post-Acute Care.
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
Relias has a grievance policy in place to facilitate reports of dissatisfaction. Relias will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias.
If you require special accommodations to complete this module, please contact Relias Support by completing the web form (https://www.relias.com/help) or by using the chat functionality.
All courses offered by Relias, 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.
Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC.
All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
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.
If you require special accommodations to complete this module, please contact Relias Customer Support here.
