• 9 minutes

Fundamentals of Documentation in the Electronic Medical Record


Identify fundamentals of documentation in the electronic medical record.

More and more health care is moving to an outpatient setting. More people are able to go in for surgery and recover at home. Some of the problems that are seen with outpatient settings are misdiagnosis or failure to diagnose cancer, heart attacks  in adults, and meningitis in children. This video reviews outpatient and inpatient settings and the common hospital admission diagnoses.

Runtime: 9 minutes



Katie Aumann Morales, Ph.D., RN, CNE

Katie Aumann Morales, Ph.D., RN, CNE

Berry College

  • Assistant professor of nursing at Berry College
  • 34 years’ experience as a nurse, 14 years’ experience as a legal nurse consultant, and 8 years’ experience in education
  • Professional presentations on nursing and education topics include Studying for Learning: Active Studying Strategies Lilly Conference on Innovative Strategies to Advance Student Learning and How Do Nurses Ensure That Patient Care Is Safe? Quest for Quality Mayo Civic Center Rochester, Minnesota
  • Publications related to nursing and nursing education include QSEN Teaching Strategies: Collaborative Exams to Promote Learning Through Teamwork and Collaboration; Sponge relay and cardiac Output; Nursing Education Perspectives: Active learning strategies to enhance nursing students’ knowledge of Pharmacology; Use of an Aquarium and Pump to Demonstrate Cardiac Function; Evidence-Based Practice; In Manning, L. & Rayfield, S. Pharmacology Made Insanely Easy and Nursing Made Insanely Easy (9th ed) and (8th ed); Nursing Management in Health Promotion, In Rayfield, T. & Rayfield, S. Keeping It Real! Simplified. (2nd ed.). Bemis, P. Emergency Nursing Bible: Principles and Practices of Complaint-based Emergency Nursing, (5th ed.) Glossary In Peterson, A. & Kopishke, L. Legal Nurse Consulting: Principles & Practice (3rd ed.). Boca Raton, FL; CRC Press Infection Control Tips; Tools for monitoring hand hygiene in a long-term care facility, Infection Peer-Reviewed Published Abstracts Testing the effect of a resident-focused hand hygiene intervention in a long-term care facility: A mixed methods feasibility study, Virginia Henderson Global Nursing e-Repository. and ProQuest Dissertations and Theses database
  • Member of Phi Kappa Phi, Golden Key International Honour Society, Association for General & Liberal Studies, Graduate Nursing Student Academy, Alpha Chi, Georgia Association for Nursing, and Sigma Theta Tau International
  • Ph.D. degree, Georgia Baptist College of Nursing of Mercer University; M.S. degree in nursing education, Grand Canyon University; B.S. degree in nursing, University of Phoenix; associate degree in nursing, Columbus State University
  • Can be contacted at 706-889-2915 or [email protected] and on Twitter® @KMorales
Megan Farrow, MSN, RN

Megan Farrow, MSN, RN

Berry College

  • Clinical instructor of Nursing at Berry College
  • Critical Care nurse since 2009 in Level 2 Trauma Center, Cardiac ICU, Neuro ICU, Med/Surg ICU
  • 4 years of education experience in clinical, classroom and simulation
  • Podium presentations include 2017- Innovation in Teaching Conference, University of Georgia, Teaching for Learning: It’s All Fun and Games; 2016- Georgia Association of Nurse Educators, Jekyll Island, GA, An Innovative Approach to EBP
  • Member of Sigma Tau Delta English Honor Society, Phi Kappa Phi Honor Society, Georgia Association of Nurse Educators and Georgia Simulation Association

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