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  • Nursing
  • Advanced Practice Nursing
Hours: 5 Contact Hours
Author(s): Kim Maryniak, RNC, BN, MSN, PhDc
Peer Reviewer(s): Chad A. Sullivan, RN, JD, CHC
Item#: N1687
Contents: 1 Course Book (94 pages)
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Documentation for Nurses: Legalities of Documentation

Price $26.95
Item # N1687
When available, the Online Course format is included with the hard copy, eBook, or audio book formats!

Release Date: December 31, 2015

Expiration Date: December 31, 2018

Nursing documentation is a critical component of nursing practice. In the instance when a nurse finds him/herself either named or called as a witness during a lawsuit, a well-documented patient medical record may help a nurse remember the patient and the situation in question. Chapter 1 of this course addresses documenting practices to decrease liability risk, the best ways to keep a nurse out of court, recommendations for creating a comprehensive and defensive medical record, and the nurse’s role in understanding documentation standards. 

It is also important for nurses to obtain knowledge to protect themselves in the defense of a suit. Chapter 2 discusses professional liability insurance; how to prepare for a lawsuit; the essentials of a successful malpractice case; how to prepare with an attorney; and conduct at a deposition or trial.

Chapter 3 focuses on accurate, complete, and timely documentation to provide clear communication and prevent potential lawsuits. Areas addressed include supervision of unlicensed patient care assistants, delegation, downsizing, short staffing, floating, missing records, correction of documentation errors, late entries, and other concerns. Techniques to decrease risks and avoid bad outcomes are integrated into each section.

Informed consent and incident reports are the final chapters of this course. Chapter 4 discusses the nurse’s professional responsibility with regard to consent forms, documentation requirements, advance directives, and the Patient Care Partnership (formerly the Patient’s Bill of Rights) and Chapter 5 addresses the purpose and use of incident reports, situations that require incident reports, documentation in the medical record, and the proper routing and location of an incident report.


This course is an extraction of, and should not be taken in conjunction with,  N1634 Documentation for Nurses, 2nd Edition (15 contact hours).

CCMs - This program has been pre-approved by the Commission for Case Manager Certification to provide continuing education credit (6 hours) to Certified Case Managers (CCMs)

Course Objectives

  • Discuss documentation practices that decrease liability risk.
  • Discuss personal professional liability insurance and the steps to take when preparing for the defense of a malpractice lawsuit.
  • Specify nursing practices that could lead to documentation disasters and potential lawsuits.
  • Identify the legal importance of, and nursing responsibilities involved with, informed consent and describe the importance of the Patient’s Bill of Rights. 
  • Identify situations that require incident reports and explain the purpose of these reports.

Kim Maryniak, RNC, BN, MSN, PhDc, has over 26 years nursing experience in medical/surgical, psychiatry, pediatrics, and neonatal intensive care nursing. She has been a staff nurse, charge nurse, educator, instructor, manager, and nursing director. Kim graduated with a nursing diploma from Foothills Hospital School of Nursing in 1989. She obtained her Bachelor in Nursing through Athabasca University in 2000 and her Master of Science in Nursing through University of Phoenix in 2005. Kim is certified in Neonatal Intensive Care Nursing and is currently pursuing her PhD in Nursing. She has been active in both the National Association of Neonatal Nurses and American Nurses Association. Kim’s current and previous roles have included professional development and practice, research utilization, nursing peer review and advancement, education, use of simulation, infection control, patient throughput, nursing operations, quality, and process improvement. She has developed educational activities for topics such as assessment, fundamentals of nursing, leadership, evidence-based practice, pain management, and specialty subjects.

Chad A. Sullivan, RN, JD, CHC, is a nurse attorney who received his Juris Doctorate from Louisiana State University in 2001. Prior to entering law school, Chad attended McNeese State University, where he obtained a Bachelor of Science in Nursing. He remains a licensed Registered Nurse in Louisiana. Chad received a certificate in Health Care Compliance from George Washington University in 2010 and is board certified in Health Care Compliance by the Health Care Compliance Association.

  • Courses must be completed on or before the expiration date noted in the course description above.
  • You must score 75% or higher on the final exam and complete the course evaluation to pass this course and receive a certificate of completion.
  • Through our review processes, Western Schools ensures that this course content is presented in a balanced, unbiased manner and is free from commercial influence. It is Western Schools’ policy not to accept commercial support.
  • All persons involved in the planning and development of this course have disclosed no relevant financial relationships or other conflicts of interest related to the course content.