Legal Considerations in Clinical Documentation

Course overview

Knowing and applying documentation principles in daily practice is essential to protecting patients and safeguarding your license. Documentation is the foundational proof that care was provided to a patient. Requirements and methods of documenting are ever-changing among a variety of documentation modalities. Although clinicians sometimes view documentation as a process that takes precious time away from direct patient care, it is one of the most critical skills they perform. In fact, appropriate and effective documentation is at the core of practice.