What are the Legal Implications of Documentation?
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.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: September 10, 2021

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:LD061521
Contact Hours:1.00
Delivery Method:Online Self Study
Category:Professional Issues
Learning Objectives
  • At the conclusion of this course, the registered nurse will be able to:

  • 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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