Medical Record Documentation & Legal Information for Florida Certified Nursing Assistants

Medical Record Documentation & Legal Information for Florida Certified Nursing Assistants 

Certified nursing assistants, or CNAs, give important and valuable care in all types of settings. Just as important as the care you give is the documentation of that care. Additionally, you must be familiar with legal aspects of care that guide your practice as a CNA. This course will offer you guidance on documentation and legal aspects of care. This course will give general information that is appropriate to all CNAs in Florida. It is also important for you to be familiar with and follow your organization’s policies and procedures.


Hours: 1.00


Certificates provided by accrediting body (2 Match)

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 1.00 contact hours.

Non-Licensed Direct Care (DSP, HHA, CNA, DCW, PCA, IHA, NA)


Course Details

Hours: 1
Type: Online Course
Content Expiration Date: 8/31/2023
Learning Objectives:
Identify the purpose of the medical record and documentation.
Explain guidelines regarding when and what to document.
Describe good documentation practices to avoid errors.
Identify legal standards that affect the certified nursing assistant.

Section 1: Introduction
A. About This Course
B. Learning Objectives
Section 2: The Medical Record and Documentation
A. The Purpose
B. Electronic Medical Records
C. Importance of Documentation
D. When to Document
E. What to Document
F. Review
G. Summary
Section 3: Documentation Best Practices
A. Painting a Picture
B. One Simple Rule
C. Good Documentation
D. Mistakes and Late Entries
E. Objective vs. Subjective Data
F. Documenting Refusals
G. Change of Condition
H. Incomplete Documentation
I. Use of Inflammatory Language
J. Documentation Examples
K. Review
L. Summary
Section 4: Legal Standards
A. Laws and Rules
B. Regulation of CNA Practice
C. Scope of Practice
D. In-Service Requirements
E. Competency
F. Maintaining Certification
G. CNA Reporting Requirements
H. Policies and Procedures
I. Review
J. Summary
Section 5: Conclusion
A. Summary
B. Course Contributors
C. References
D. Congratulations!

Instructor: Faith Williams, RN, BS in HCA
Faith is a registered nurse and earned a BS in Health Care Administration at St. Leo College in St. Leo, Florida. She has an extensive background in home health education, nursing and healthcare administration. Subsequent to the years in home health, she has worked for companies who provide on-line education to healthcare providers and workers in the acute and subacute markets. She has authored various education programs and procedure manuals, as well as presented to and educated both clinical staff and the general public. Disclosure: Faith Williams, RN, BS in HCA has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Target Audience:
The target audience for this course is: Entry level Direct Care Workers; in the following settings: All Healthcare Settings.
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Course Delivery Method and Format
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 ( 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.