Legal Issues for Nursing Documentation, 4th Edition


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About the Course
It is important for nurses to be able to identify areas of nursing practice that pose a risk for legal consequences so that they can take steps to protect themselves and avoid unfavorable patient outcomes. A well-documented patient record is one method to mitigate these risks. In addition to discussing the legal aspects of nursing documentation, this course will outline proper documentation techniques to avoid legal entanglement, including the use of consent forms in patient care and the need for incident reports to document adverse events.

Learning Outcomes
After completing this course, the learner will be able to:
  • Identify areas of nursing practice that pose a risk for legal consequences and the proper documentation techniques that can be used to mitigate that risk.
  • Discuss legal considerations in documentation practices, including liability risk, professional liability insurance, and preparation for legal defense.
  • Discuss the legal importance of and nursing responsibilities in connection with informed consent and the importance of the Patient Care Partnership.
  • Explain the need for incident reports in nursing practice and the proper method of documentation.

About the Author
Margaret-Ann Carno, PhD, MBA, MJ, PNP-PC, D ABSM, FAANis an educator, practitioner, and researcher. Her passions are healthcare law, regulations, and research regulations. She obtained a Master’s in Jurisprudence from Loyola University Chicago, School of Law, with a concentration in Health Law. She regularly teaches on these subjects.

How to Receive Credit:
  • Read the entire course online or in print which requires a 6-hour commitment of time.
  • Complete the Self-Assessment Quiz Questions either integrated throughout or all at the end of the course.
    • These questions are NOT GRADED. The questions are included to help affirm what you have learned from the course.
    • The correct answer is shown after the question is answered. If the incorrect answer is selected, a Rationale for the correct answer is provided.
  • At the end of the course, answer the Yes/No Affirmation question to indicate that you have completed the educational activity.
  • Specific to Florida: A mandatory Final Examination with a passing score of 70% or higher is required. Exam questions link content to the course Learning Objectives as a method to enhance individualized learning and material retention.
  • If requested, provide required personal and payment information.
  • Complete the mandatory Nursing Course Evaluation.
  • Print your Certificate of Completion.
Resolution of Conflict of Interest
In accordance with the ANCC Standards for Commercial Support for continuing education, Colibri Healthcare, LLC implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity.

Sponsorship/Commercial Support and Non-Endorsement
It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition ©2021: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Colibri Healthcare, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up-to-date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers.

Course Verification
All individuals involved have disclosed that they have no significant financial or other conflicts of interest pertaining to this course. Likewise, and in compliance with California Assembly Bill No. 241, every reasonable effort has been made to ensure that the content in this course is balanced and unbiased.