The Legal Aspects of Documentation

The Legal Aspects of Documentation 

As a healthcare professional, you have often heard the adage that says, "If you didn’t document something, you didn’t do it." It is no longer true that you can be exempt from malpractice or negligence claims because you were following orders. As a professional in the healthcare industry, you are expected to be familiar with many aspects of care. If you are a nurse, you are responsible for assessing, planning, implementing, and evaluating nursing care. If you are a social worker, you are responsible for assessing, planning, implementing, and evaluating psychosocial care. What you document can and does reflect the care provided and the resulting outcome when the documentation is factual, complete, timely, and detailed. In this course, you will learn about concepts and rules regarding documentation in the medical record as it relates to negligence, malpractice, and civil litigation.


Hours: 1.25


Certificates provided by accrediting body (0 Match)

Course Details

Course Code: REL-PAC-0-LAD
Hours: 1.25
Type: Online Course
Content Expiration Date: 12/31/2022
Learning Objectives:
Define malpractice and negligence as they relate to nursing and social work practice.
Describe two elements of proof in malpractice litigation.
Differentiate between compensatory and punitive damages.
Explain four intentional torts that a healthcare professional may be held liable for.
Describe four techniques you should use when documenting care to avoid legal issues.

Section 1: Introduction

About This Course

Learning Objectives

Section 2: Negligence and Malpractice

Nursing Practice

Social Work Practice

Importance of Documentation

Negligence and Malpractice



Section 3: Proving Negligence and/or Malpractice

The Four Elements of Proof


Failure to Observe

Failure to Intervene

Failure to Protect

Breach in Standard of Care

Causation or Intention

Damages or Harm



Section 4: Intentional Torts

Examples of Intentional Torts




Breach of Promise




Invasion of Privacy

Infliction of Emotional Distress


False Imprisonment



Section 5: Documentation

Criteria for Documentation

Documentation Tips

The Do’s

The Don’ts

Actions for Self-Protection

Documentation and the EHR



Section 6: Conclusion


Course Contributors





Instructor: Lynn J. Grams, RN, BA, M.Ed.
Lynn Grams is a registered nurse in the state of Florida. She has an advanced degree in Adult Education with extensive experience in Nursing Education. At the Education Departments in Acute Care Hospital setting, she has been both instructor and department director since her arrival in Florida in 1974. Her past experience includes nursing supervision in acute care hospital setting as well. Prior to relocating to Florida she was employed as a staff nurse in ICU and Surgical units, Head Nurse of a Medical Surgical Unit, and two years as an instructor in a 3 year diploma nursing school. Disclosure: Lynn J. Grams, RN, BA, M.Ed. has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Instructor: Kim Matthews, RN
Kimberly Matthews, RN obtained a nursing degree from Western Kentucky University in 1998.  Ms. Matthews possesses over 20 years of nursing experience with over 17 of those in the Skilled Nursing industry.  Ms. Matthews has extensive experience in MDS, restorative nursing programs, and nursing management.  Ms. Matthews is currently a Post Acute Care Content writer and subject matter expert for MDS. Disclosure: Kim Matthews, RN 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: Nurses; in the following settings: Post-Acute Care.
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.