Documentation for Nurses: A Basic Guide to Avoid Litigation

Accurate documentation is not just a best practice—it’s a legal safeguard and a professional obligation. In the demanding environment of modern healthcare, even minor lapses in record-keeping can have serious repercussions. This course is designed to help nurses at all levels improve their documentation practices to better protect their licenses and deliver higher-quality care.

Participants will examine the essential elements of proper documentation, with practical guidance on avoiding common errors that could contribute to adverse events or malpractice claims. Real-world examples and legal insights bring the content to life, making this a valuable learning tool for both new and experienced nurses.

Key Topics Covered:

• The legal significance of nursing documentation in patient care.
• Frequent charting mistakes that can lead to negligence claims.
• Core strategies for maintaining accurate, clear, and defensible medical records.

By the end of this course, you’ll be equipped to create documentation that meets legal, ethical, and clinical standards—boosting your confidence and your contribution to safe, effective care.

Course Completion Requirements:

To receive full contact-hour credit, participants must:

• Be registered for this course.
• Review all course materials.
• Complete the post-test with a score of 70% or higher.
• Submit the course evaluation survey.

Note: Some courses may also include participation in discussion boards, practice exercises, or additional activities.

Important Disclosures:

• Conflict of Interest: The content creators and faculty have no financial or personal relationships to disclose.
• Commercial Support: No external or commercial sponsorship was received for this activity.
• Non-Endorsement: Approval of this activity does not imply endorsement of any commercial products or services.
• Off-Label Product Use: No discussion of off-label use of medications or devices is included.