Documentation: The Legal Side
As a professional nurse, you are expected to be familiar with many aspects of care. You are not exempt from malpractice or negligence claims because you were following orders. You are responsible for assessing, planning, implementing, and evaluating appropriate nursing care. What you document can and does reflect the care provided and the outcomes of that care. Documentation that is factual, complete, timely, and detailed is required. In this course, you will learn about concepts and rules regarding documentation in the medical record. Legal aspects to be aware of while practicing will also be discussed. The goal of this course is to educate nursing professionals in post-acute care settings about the legal implications of documentation.
As a professional nurse, you are expected to be familiar with many aspects of care. You are not exempt from malpractice or negligence claims because you were following orders. You are responsible for assessing, planning, implementing, and evaluating appropriate nursing care. What you document can and does reflect the care provided and the outcomes of that care. Documentation that is factual, complete, timely, and detailed is required. In this course, you will learn about concepts and rules regarding documentation in the medical record. Legal aspects to be aware of while practicing will also be discussed. The goal of this course is to educate nursing professionals in post-acute care settings about the legal implications of documentation.
American Nurses Credentialing Center
In support of improving patient care, Relias LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Nurses will receive 1.00 Nursing Contact Hours after successfully completing this course.
Arkansas State Board of Nursing
Arkansas State Board Of Nursing Approved Continuing Education program (CEBroker Provider #50-290).
Nurses will receive 1.00 contact hours for participating in this course.
California Board of Registered Nursing
Provider approved by the California Board of Registered Nursing, CEP# 13791
Nurses will receive 1.00 contact hours for participating in this course.
District of Columbia Board of Nursing
District of Columbia Board of Nursing Approved Continuing Education program (CEBroker Provider #50-290).
Nurses will receive 1.00 contact hours for participating in this course.
Florida Board of Nursing
Florida Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Georgia Board of Nursing
Georgia Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Kentucky Board of Nursing
Kentucky Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Michigan Board of Nursing
Michigan Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Mississippi Board of Nursing
Mississippi Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
New Mexico Board of Nursing
New Mexico Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
North Dakota Board of Nursing
North Dakota Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
South Carolina Board of Nursing
South Carolina Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
West Virginia Board of Registered Nursing
West Virginia Board of Registered Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Discuss malpractice, negligence, and compensatory and punitive damages as they relate to healthcare.
Explain four intentional torts that a healthcare professional may be held liable for.
Describe four documentation techniques to use to avoid legal issues.
Outline:
Section 1: Introduction
About This Course
Learning Objectives
Section 2: Negligence and Malpractice
Nursing Accountability
Importance of Documentation
Negligence and Malpractice
The Four Elements of Proof
Duty
Breach
Causation or Intention
Damages or Harm
Review
Summary
Section 3: Intentional Torts
Examples of Intentional Torts
Assault
Battery
Abandonment
Breach of Promise
Fraud
Conversion
Infliction of Emotional Distress
False Imprisonment
Review
Summary
Section 4: Documentation
Documentation
Who Should Document Care?
Why is Documentation Important?
When and Where Should You Document?
What Should Documentation Include?
How to Document
Care Plans
Written Entries
Electronic Entries
Other Tips and Tricks
How to Protect Yourself
Review
Summary
Section 5: Conclusion
Course Summary
Course Contributor
Resources
References
Tameka N. Warren, MSN, RN, CLC, earned her Bachelor and Master of Science in Nursing degrees from Indiana University School of Nursing at IUPUI, and her Associate of Science in Nursing from Ivy Tech College. She has over 19 years of nursing experience in public health, regulation, home health, leadership, education, maternal child community health, and long-term care environments. Tameka has served as a leader in home healthcare practices, quality improvement, and education as a community health nurse and a Public Health Nurse Surveyor (Home Health & Hospice) certified by CMS for a State Agency. She has served as a maternal and infant mortality advocate in managing home visiting services, supporting legislation to improve maternal child care in diverse communities, and as an ALPP Certified Lactation Counselor. She has also served as an Adjunct Clinical Professor to further awareness about the importance of community health nursing. Tameka’s passion is to serve the most vulnerable populations affected by health disparities and to inspire a new generation of nurses to do the same successfully.
The target audience for this course is: Nurses; in the following settings: Post-Acute Care.
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 (https://www.relias.com/help) 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.
