Observing, Reporting, and Documenting

Course Code: REL-PAC-0-OBSRD

Hours: 1

Type: Online Course

Content Expiration Date: 12/31/2028

Learning Objectives:
Recall when you are legally required to report concerns about a person’s safety or well-being.
Recognize what to look for when observing a person’s condition, environment, and behavior.
Identify best practices for reporting and documenting care and observations.

Outline:
Section 1: Recognizing Changes

Observation Skills

Your Role as an Observer

Why Your Observations Matter

What Does “Normal” Look Like?

How to Observe

Knowledge Check

Key Takeaways

Section 2: Reporting Concerns

Reporting Changes

Why Reporting Matters

Reporting Health and Safety Concerns

Reporting Abuse or Neglect

Using SBAR to Report

Who Do You Report To?

Common Mistakes

Knowledge Check

Key Takeaways

Section 3: Documenting Care

Clear and Accurate Notes

Why Documentation Matters

What Makes a Good Report

Documentation Mistakes

Correcting Errors

When to Document

Documentation Tools

Protecting Privacy

Knowledge Check

Key Takeaways

Section 4: Conclusion

Course Summary

Course Contributor

References

Subject Matter Expert: Jaclyn Armstrong, BSN, RN, HCS-O

Jaclyn Armstrong is a Registered Nurse and certified Home Care Clinical Specialist- OASIS (HCS-O). She earned a Bachelor of Arts in Psychology from the University of North Carolina Wilmington and a Bachelor of Science in Nursing from Belmont University. Prior to joining Relias as a subject matter expert and writer for post-acute care, she gained extensive experience in home health with a strong focus on quality improvement and patient outcomes.

Target Audience:
The target audience for this course is: Direct Care Staff; Unlicensed Personnel; in the following settings: Assisted Living Facility, Home Health Agencies, Skilled Nursing Facility.

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