Documentation and Legal Aspects - Nurses

Throughout this course we will review:

• Identify the first and most important rule of medical documentation.
• Identify three reasons why everything concerning a patient's care must be documented.
• Identify three aspects of proper documentation.
• Identify the four "do's" of proper documentation.
• Identify the three "don'ts" of proper documentation.
• Identify a note that is an example of poor documentation.
• Identify a note that is an example of good documentation.
• Identify three things that a health care worker may document about their patient.
• Identify the proper way to document a note that is entered in late.
• Identify what is important to document when performing a therapeutic activity.

Upon completion of this program, participants should be able to:

• Describe why all healthcare workers need to be concerned with liability
• How to correctly document patient interactions
• Why it's important to document properly for clear communication betwen healthcare professionals
• Throughout this course wntation and what to look for in reports
• Define significant key terms that correlate directly with documentation and its legality.
• Explain how a healthcare assistant is obligated to maintain patient confidentiality
• Do's and Dont's of documentation and their meanings