Nursing: Legal Considerations in Nursing Documentation, 3rd Edition

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About the Course

Nursing practice involves all tangible and intangible activities performed by nurses whenever they interact with a patient. The adage “if it isn’t documented, then it wasn’t done” is essential to remember in nursing practice.  A well-documented patient record is critical for nurses to prevent unfavorable patient outcomes and avoid legal consequences. This course presents the legal aspects of nursing documentation, including the use of consent forms in patient care, documentation techniques to mitigate risk, and the necessity of incident reports to document adverse events. 

Learning Outcomes:
Upon completion of 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:

Kim Maryniak, PhD, MSN, BN, RNC-NIC, NEA-BC

Kim Maryniak, PhD, MSN, BN, RNC-NIC, NEA-BC, has more than 29 years of nursing experience with medical-surgical, psychiatry, pediatrics, progressive care, and adult and neonatal intensive care. She has been a staff nurse, charge nurse, educator, instructor, manager, and nursing director. Dr. Maryniak graduated with a nursing diploma from Foothills Hospital School of Nursing in Calgary, Alberta, in 1989.  She obtained her Bachelor of Science in Nursing from Athabasca University, Alberta, in 2000, her Master of Science in Nursing from the University of Phoenix in 2005, and her PhD in nursing from University of Phoenix in 2018. Dr. Maryniak is certified in neonatal intensive care nursing and as a nurse executive, advanced. She is active in the American Nurses Association, American Organization of Nurse Executives, and Sigma Theta Tau. Her current and previous roles include research utilization, nursing peer review and advancement, education, use of simulation, quality, process improvement, leadership and professional development, infection control, patient throughput, nursing operations, professional practice, and curriculum development.

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