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Legal Issues in Documentation




  • Discusses specific legal principles relating to the provision of medical and nursing care
  • Explains the processes when nursing records are called into question
  • Points out the advantages of keeping records updated

At no point can you afford to be careless in your attitude towards documenting nursing care. Inadequate records may give the client's account of the circumstances surrounding the care more credence than your hazy recollection. In this chapter, learn about the importance of contemporaneous record keeping, about the legal complications of poor documentation and more.


Contents include

  • Principles Of Legally Correct Documentation
  • When Nursing Records Are Called Into Question
    • Civil Suits
    • Coronial Inquiry
  • The Value Of Well-Kept, Contemporaneous Records
    • The Legal Consequences Of Poor Documentation
  • In Summary
  • Suggested Reading
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