Documentation for Nurses: A Basic Guide to Avoid Litigation

Participants will gain a comprehensive understanding of the legal principles surrounding medical documentation, including its role as a primary source of evidence in malpractice claims, licensure investigations, and institutional audits. The course outlines best practices for charting in real time, objective documentation, use of standardized language, and error correction in both paper and electronic health records (EHRs). Emphasis is placed on clinical clarity, continuity of care, and defensibility in legal proceedings.

Learning Objectives:

• Upon successful completion of this course, participants will be able to:
• Define the legal and regulatory importance of accurate nursing documentation.
• Identify key elements of defensible documentation and avoid common charting errors.
• Apply strategies to document patient care, communication, and clinical decision-making clearly and objectively.
• Understand the implications of omissions, alterations, or vague entries in medical records.
• Recognize high-risk documentation scenarios that may expose nurses to litigation.
• Integrate institutional policies and standards into daily documentation practices.

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 include additional requirements, such as participation in discussion boards or completion of practice exercises.

Important Disclosures:

• Conflict of Interest: The course planners, authors, and presenters have no financial or commercial conflicts of interest related to this educational activity. 
• Commercial Support: This course has not received any sponsorship or financial support from commercial entities. 
• Non-Endorsement: Approval of this course as a continuing education activity does not imply endorsement of any products, services, or companies mentioned within the content. 
• Off-Label Product Use: No information related to off-label use of FDA-approved products is included in this course.