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Best Practices in Nursing Documentation: Writing Effective and Legal Proof Notes

OnDemand Webinar (88 minutes)

Understand the compliance challenges in documentation and make medical records as accurate as possible. Long gone are the days that nurses and other health care providers hand-wrote cryptic notes on essay paper-like chart pages that rarely were ever looked at again. Long gone, also, are the days that physicians would only look at labs, reports and other physicians' notes, expecting the nurse to call to the physician's attention anything important about the patient so they didn't have to read nurses' notes. The information documented about a patient will live on and be seen by a multitude of individuals. It has become even more important to document accurately, succinctly, intelligibly and professionally. This topic will place documentation of patient care in its rightful place, summarize its multiple purposes, describe appropriate documentation, and highlight pitfalls of bad documentation and its consequences. This topic will introduce you to how the legal system uses documentation, techniques to avoid problems and what you might be required to do at some time in the future with respect to your documentation or lack thereof. The standards that are applied to documentation will also be discussed briefly. Last, but not least, you will be able to ask questions and will learn from unfortunate examples of others' documentation and the consequences of those failures.


Diane M. Janulis, J.D., M.S.N., B.S.N.


Medical Record or Medical Information

• What Comprises Patient Information That Can Be Used in Legal Proceedings?

• What Lawyers or Administrative or Investigative Bodies Can Obtain

• What Can a Health Care Provider Be Required to Disclose? How, When and Where

Purposes of Documentation of Medical Care

• Historical Documentation of Care Provided

• Communication Tool for Other Health Care Providers

• Evidence in Legal Proceedings

• Statistical Data, Reimbursement, Quality Assurance, Epidemiological Studies

Recent ICD 10 and Legal Implications

HIPAA and Selected Impact on Documentation

• Security and Privacy Rule

• Protected Health Information

• Legal Health Record

• Electronic Health Record

• Potential Breaches of Privacy Rule and Penalties

Documentation - the Good, the Bad and the Plain Ugly

• Characteristics of Good Documentation

• Standards for Documentation

• Examples of Bad or Ugly Documentation

• Electronic Communication Issues

The Medical Record as Evidence

• How It Is Used

• Depositions - What Are They and What You Should Expect and Require

Additional Formats

Audio & Reference ManualMore Info