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The Legal Side of Nursing Documentation:
                                                             Strategies to Keep You Out of the
                                                                                   Courtroom




              Medical Legal Concepts
ADDRESSING THE NEEDS OF
N U R S E S T O PROTECT THEIR
                                                      Seminars
NURSING LICENSE


Medical Legal Concepts Seminars
Legal Documentation Seminars for Nurses
The What, Why, and How



The Necessities
Why do nurses need seminars on the legal
aspects of documentation?
Nursing training is vocational and        deficiencies. They may also include
includes skills, knowledge, and a         the relief of symptoms and pain, us-
system of thought that is based on        ing a full scope of medical interven-
the values, characteristics, and be-      tions. In the process of, and follow-
haviors believed to be best in hu-        ing medical interventions, the ex-
man beings. Nurses carry out many         pected results may not always be
roles and functions within a team of      achieved, and a person who is re-
healthcare providers including            ceiving treatment may suffer harm
providing patient care, decision          as a result. In this situation, the
making, protecting patients’ rights,      legality of the medical procedures or    or physician causes harm
and providing information. With the       nursing interventions and the issues     and/or loss; for example, by
evolution of technology, nurses are       of the resultant responsibility of the   not providing adequate service
confronted with issues of malprac-        person or individuals who caused         and care in suitable condi-
tice in their practice as the interven-   the harm may be questioned, which        tions, by not matching the per-
tions become more invasive.               may lead to an investigation of med-     formance expected from a
                                          ical malpractice.                        nurse under the same or simi-
Medical procedures include the ap-                                                 lar conditions, or by departing
plication of medical and nursing sci-     Malpractice can be defined as lack       from the requirements of ac-
ence while following accepted rules       of knowledge or experience, or negli-    cepted practice, leading to
and processes to effect the diagnosis     gence, in the performance of duties      substandard care or a breach
and treatment of an individual’s          that result in patient injury. Medi-     in the standard of care.
physical or psychological illnesses or    cal malpractice occurs when a nurse
“...that adverse events during the course of care
                                  contributes to the deaths of 180,000 patients
                                  every year...”   
                                                                                           How easy is
                                   
                                  —November 2010 report released by the Office of          it to book a
                                                         
                                                                                           seminar?
                                  the Inspector General

                               Criminal charges for          practice, and ways of
                               nursing errors are be-        preventing malpractice
                               coming more prevalent         and related problems
                               than ever before. The         by defining the relevant
                               differences between al-       issues. The only way
There has been an in-          legations in the civil        for a nurse to protect
crease in the number of        system and the charges        against the possibility
malpractice cases in part,     brought in the criminal       of facing allegations of
                               systems must be un-           substandard care for a         Booking a seminar is
due to an increased
                                                                                            extremely easy. The
awareness of patients’         derstood.                     nursing error is
                                                                                            online website through
and consumers’ rights.                                       through good nursing           National Speakers Asso-
                                The scope and content        practice and document-
Nurses have to bear                                                                         ciation (NSA) http://
                               of topics presented by        ing the same.                  www.nsaspeaker.org
heavy responsibilities.
                               Medical Legal Concepts                                       provides the information
Failure to fulfill these re-
                               seminars are intended                                        needed to contact the
sponsibilities may result
                               to raise awareness of          “We have an epi-              speaker and request
in allegations of negli-                                      demic of medical              dates for booking. You
                               malpractice as part of
gence that can lead to                                        malpractice, not of           can view her schedule
                               nursing practice. When
malpractice lawsuits.                                         malpractice law-              and then you can speak
                               nursing training does
Allegations of negligence                                     suits.”                       directly with customer
                               not create an aware-                                         service at: 800-259-
can arise against a nurse
                               ness of malpractice is-        Tom Baker, Professor of       8058 to finalize your
from almost any action or                                     Law, Univ. of PA.
                               sues, it lays a founda-                                      date.
failure to act that results
                               tion for malpractice,
in patient injury (most
                               whether it is intentional
often, an unintentional                                                                Medical Legal Concepts, LLC
                               or unintentional. The
failure to adhere to a                                                         6231 PGA Blvd, Suite 104, PMB #243
                               legal seminar presented
standard of clinical prac-                                                        Palm Beach Gardens, Florida 33418
                               addresses related laws
tice) and may lead to a                                                            T: 800-259-8058 F: 561-799-3994
                               and regulations, mal-
malpractice lawsuit.                                                           http://www.medicalegalconcepts.com

                                                                          You will receive perspectives on nursing
Advantages of Legal Seminars                                              leadership in regulation.

by Medical Legal Concepts                                                 You will learn how to correctly document
                                                                          medical errors and how to safely report
                                                                          them to the appropriate individual.
Attending a legal seminar by         You will become more aware of
MLC assures you to receive           your practice limits and the         You will learn of vulnerabilities posed by
current, relevant and accurate       vulnerabilities of functioning       the use of electronic medical records and
information that will reduce         outside them.                        recording electronically.
your exposure to liability.
                                     You will feel confident when to      You will learn of strategies that you can
You will learn at least 10 ways      execute the chain of com-            immediately apply to your nursing prac-
to avoid mistakes in the work-       mand.                                tice that will significantly reduce your ex-
place.                                                                    posure to litigation.
                                     You will improve the reflection
You will learn from real case        of quality patient care, thereby     You will enjoy learning this most sensitive
studies that have been litigat-      reducing exposure of litigation      and sometimes threatening topic from the
ed involving nurses in clinical      proceedings to your facility.        charismatic methods Rachel uses in her
practice.                                                                 presentations.

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Nursing Documentation Whitepaper

  • 1. The Legal Side of Nursing Documentation: Strategies to Keep You Out of the Courtroom Medical Legal Concepts ADDRESSING THE NEEDS OF N U R S E S T O PROTECT THEIR Seminars NURSING LICENSE Medical Legal Concepts Seminars Legal Documentation Seminars for Nurses The What, Why, and How The Necessities Why do nurses need seminars on the legal aspects of documentation? Nursing training is vocational and deficiencies. They may also include includes skills, knowledge, and a the relief of symptoms and pain, us- system of thought that is based on ing a full scope of medical interven- the values, characteristics, and be- tions. In the process of, and follow- haviors believed to be best in hu- ing medical interventions, the ex- man beings. Nurses carry out many pected results may not always be roles and functions within a team of achieved, and a person who is re- healthcare providers including ceiving treatment may suffer harm providing patient care, decision as a result. In this situation, the making, protecting patients’ rights, legality of the medical procedures or or physician causes harm and providing information. With the nursing interventions and the issues and/or loss; for example, by evolution of technology, nurses are of the resultant responsibility of the not providing adequate service confronted with issues of malprac- person or individuals who caused and care in suitable condi- tice in their practice as the interven- the harm may be questioned, which tions, by not matching the per- tions become more invasive. may lead to an investigation of med- formance expected from a ical malpractice. nurse under the same or simi- Medical procedures include the ap- lar conditions, or by departing plication of medical and nursing sci- Malpractice can be defined as lack from the requirements of ac- ence while following accepted rules of knowledge or experience, or negli- cepted practice, leading to and processes to effect the diagnosis gence, in the performance of duties substandard care or a breach and treatment of an individual’s that result in patient injury. Medi- in the standard of care. physical or psychological illnesses or cal malpractice occurs when a nurse
  • 2. “...that adverse events during the course of care contributes to the deaths of 180,000 patients every year...”    How easy is   —November 2010 report released by the Office of it to book a   seminar? the Inspector General Criminal charges for practice, and ways of nursing errors are be- preventing malpractice coming more prevalent and related problems than ever before. The by defining the relevant differences between al- issues. The only way There has been an in- legations in the civil for a nurse to protect crease in the number of system and the charges against the possibility malpractice cases in part, brought in the criminal of facing allegations of systems must be un- substandard care for a Booking a seminar is due to an increased extremely easy. The awareness of patients’ derstood. nursing error is online website through and consumers’ rights. through good nursing National Speakers Asso- The scope and content practice and document- Nurses have to bear ciation (NSA) http:// of topics presented by ing the same. www.nsaspeaker.org heavy responsibilities. Medical Legal Concepts provides the information Failure to fulfill these re- seminars are intended needed to contact the sponsibilities may result to raise awareness of “We have an epi- speaker and request in allegations of negli- demic of medical dates for booking. You malpractice as part of gence that can lead to malpractice, not of can view her schedule nursing practice. When malpractice lawsuits. malpractice law- and then you can speak nursing training does Allegations of negligence suits.” directly with customer not create an aware- service at: 800-259- can arise against a nurse ness of malpractice is- Tom Baker, Professor of 8058 to finalize your from almost any action or Law, Univ. of PA. sues, it lays a founda- date. failure to act that results tion for malpractice, in patient injury (most whether it is intentional often, an unintentional Medical Legal Concepts, LLC or unintentional. The failure to adhere to a 6231 PGA Blvd, Suite 104, PMB #243 legal seminar presented standard of clinical prac- Palm Beach Gardens, Florida 33418 addresses related laws tice) and may lead to a T: 800-259-8058 F: 561-799-3994 and regulations, mal- malpractice lawsuit. http://www.medicalegalconcepts.com You will receive perspectives on nursing Advantages of Legal Seminars leadership in regulation. by Medical Legal Concepts You will learn how to correctly document medical errors and how to safely report them to the appropriate individual. Attending a legal seminar by You will become more aware of MLC assures you to receive your practice limits and the You will learn of vulnerabilities posed by current, relevant and accurate vulnerabilities of functioning the use of electronic medical records and information that will reduce outside them. recording electronically. your exposure to liability. You will feel confident when to You will learn of strategies that you can You will learn at least 10 ways execute the chain of com- immediately apply to your nursing prac- to avoid mistakes in the work- mand. tice that will significantly reduce your ex- place. posure to litigation. You will improve the reflection You will learn from real case of quality patient care, thereby You will enjoy learning this most sensitive studies that have been litigat- reducing exposure of litigation and sometimes threatening topic from the ed involving nurses in clinical proceedings to your facility. charismatic methods Rachel uses in her practice. presentations.