Medical Record Documentation and Legal Aspects Appropriate to Nursing Assistants

Course overview

Documentation is needed to provide high quality patient care. This course presents general documentation principles. Your facility has specific standards for documentation. Whether your facility uses computers for documentation or paper forms, you will find the same principles apply. Documentation can be used as legal evidence to defend you and your facility. It can protect against allegations of malpractice, negligence, or failure to meet standards of care. It also is a key communication tool to other care providers.