Legal Implications in Nursing Documentation
Presented by Cathleen Armato
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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
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…
Chapters & learning objectives
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.
