Documentation: What are the Legal Implications?
The goal of this course is to provide the registered nurse with clear, concise guidelines to effective documentation; to enhance nursing practice by the creation of an objective medical record that meets mandated regulatory and compliance requirements; and to provide the registered nurse with the knowledge to create a medical record that will support oral testimony in a court of law.

Course Publication Date: January 07, 2019

This course is available with NO ADDITIONAL FEE if you have an active one year unlimited membership!

Author:Denise L. Gray RN, MAS, BSN, CCM
Course No:DOC123018
Contact Hours:1.00
Delivery Method:Online Self Study
Category:Professional Issues
  

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Learning Objectives
  • Identify four purposes of the medical record.
  • Describe one instance of incorrect documentation.
  • List how a late entry should be placed in the medical record.
  • Describe what the terms “objective charting” mean.
  • Identify the three components that must be included in documenting a patient’s pain.


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