Legal Implications in Nursing Documentation

presented by Cathleen Armato, RN, CHC

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Financial: Cathleen Armato receives compensation from MedBridge for this course. There is no financial interest beyond the production of this course.

Non-Financial: Cathleen Armato has no competing non-financial interests or relationships with regard to the content presented in this course.

Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

MedBridge is committed to accessibility for all of our subscribers. If you are in need of a disability-related accommodation, please contact [email protected]. We will process requests for reasonable accommodation and will provide reasonable accommodations where appropriate, in a prompt and efficient manner.

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Video Runtime: 16 Minutes; Learning Assessment Time: 14 Minutes

Nursing documentation is the primary evidence that a nurse followed the standards of care and provides the nurse with credibility in a malpractice claim. This course reviews the legal implications of documentation and common errors found in clinical records. Examples of incorrect charting will be reviewed with appropriate alternative ways to document findings. This course also discusses patient-centric documentation to support quality care. Through appropriate and strong documentation, the nurse is better positioned to support following the patient's plan of care and to defend against a malpractice claim.

Meet Your Instructor

Cathleen Armato, RN, CHC

Cathleen Armato is an experienced executive with 22 years in the home care and hospice industry. She has served in various roles during that time, including VP of operations and chief compliance officer for a nationwide healthcare provider. In 2012, Cat became a consultant. Since that time, she has assisted multiple organizations with their compliance…

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1. Legal Considerations and Documentation Risks

In any legal action involving a claim of malpractice, the clinical record is considered the most credible source of information. This chapter reviews these legal considerations and addresses risky documentation practices that could place a nurse at risk.

2. Documentation Errors

This chapter reviews common documentation errors and damaging documentation practices. Examples of risky documentation and alternative documentation techniques will be reviewed. This chapter also discusses the nurses use of diagnoses and the importance of using only appropriate nursing diagnoses and not medical diagnoses.

3. Documentation for Success

Good nursing documentation is patient-centric and factual. By using complete, clear, concise, and objective documentation, the nurse has a stronger position in legal proceedings. This chapter discusses the benefits to patients and providers and provides tips for successful documentation.

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