Documentation for Nurses: A Basic Guide to Avoid Litigation

1 CE Hr
Documentation for Nurses: A Basic Guide to Avoid Litigation


The Medical Record of a patient is a legal document that can carry ramifications not only for the patient, but for each and every healthcare provider who has a signature on any piece of paper in the chart. Therefore, any error in documentation can lead to injury for the patient or further legal trouble for the nurse down the road. This course discusses the concepts of medical record, professional negligence, and what errors to avoid in documentation.

Target Audience

This course is designed for nurses in all settings seeking to enhance their knowledge of nursing care documentation and its legal ramifications.


Upon completion of this course, participants will be able to:

  1. Understand the concept of professional negligence.
  2. Understand the concepts of breach of duty and breach of care.
  3. Avoid errors in documentation.
  4. Define what the patient’s medical record is.
  5. Describe tips to catch red flags to avoid in nursing documentation.

Completion Requirements

In order to receive full contact-hour credit for this CNE activity, participants must:

  • Be registered for this activity,
  • Review the course material,
  • Complete the course post-test and obtain a grade of 70% or higher,
  • Complete and submit the course evaluation survey.
  • Other requirements for some of the courses may also include participation discussion boards, practice exercises, practice questions, etc.

Conflict of Interest (or lack thereof) for Planners, Authors and Presenters

A conflict of interest exists if any individual/entity that is in a position to influence the content, design, or implementation of the CNE activity is ALSO in a position to benefit financially from the success of a CNE activity.

The planners, authors and presenters of this CNE activity have disclosed no conflict of interest including no relevant financial relationships with any commercial companies pertaining to this CNE activity.

Commercial/Sponsor Support

There is no commercial company or sponsor support for this CNE activity.

Non-Endorsement of Products

The National Healthcare Institute CNE provider approval status refers only to continuing nursing education activities and does not imply that there is a real or implied endorsement of any product, service, or company referred to in this activity nor of any company subsidizing costs related to the activity.

Off-Label Product Use

This CNE activity does not include any unannounced information about off-label use of a product for a purpose other than that for which it was approved by the Food and Drug Administration (FDA).

Course Aprrovals

Nursing Board Approvals

National Healthcare Institute (NHI) is an approved provider of continuing nursing education by the California*, Florida and District of Columbia Board of Nursing. All CNE courses offer by National Healthcare Institute follow the standards recommended by the American Nurses Credentialing Center’s Commission on Accreditation for this type of educational activities.

California Board of Registered Nursing*

Registered Nurse

District of Columbia Board of Nursing

Licensed Practical Nurse
Registered Nurse
Registered Nurse Anesthetist
Clinical Nurse Specialist
Clinical Nurse Midwife
Nurse Practitioner

Florida Board of Nursing

Licensed Practical Nurse
Registered Nurse
Clinical Nurse Specialist
Advanced Registered Nurse Practitioner

* Please note that the California Board of Registered Nursing (aka Registered Nursing Program) does not approve individual courses; however, as an approved CE provider (CA Provider 15701), National Healthcare Institute offers course content and utilize instructors who meet the requirements of Sections 1456 and 1457, Title 16, of the California Code of Regulations in order to meet the CE requirements for nurses in the State of California.


  • Number: CE120006
  • CE Broker ID: 20-340110
  • Contact hours: 1 CE Hr
  • Price: $4.95
  • Expiration date: Friday, 20 October 2017