Course Curriculum

This program will cover the basics of documentation, including the American Nurses
Association’s (ANA) principles, as well as expectations from the Centers for Medicare
and Medicaid Services (CMS) and the Joint Commission. The legal implications
surrounding documentation will also be addressed. Included in the discussion will be
case studies that show how the content, or lack thereof, resulted in a decision either
for the health care provider or the plaintiff.

Learning Objectives
At the conclusion of this session, participants should be able to:
• Recall the American Nurses Association’s principles for nursing
documentation.
• Describe the regulatory and professional requirements and expectations for
documentation.
• Recite that the basic requirements for documentation are clear, accurate,
timely and complete.
• Demonstrate the importance of documentation in preventing and/or
defending medical malpractice cases.