Medical records, documentation, and the law

Medical records, documentation, and the law

This 3 hour interactive course is aimed at nurses and midwives and outlines the practical ethical and legal reasons for maintaining proper patient records. It also details what medical records are, and how to maintain them as instructed.

Health Staff Ed
Updated Jun 26, 2019

Course Overview

The ever increasing complexities of healthcare service delivery means all those involved in the care of patients need to know exactly what is required - legally and ethically - to maintain proper patient records and how to do this.

This course provides comprehensive, interactive learning, using case based scenarios and legal cases to facilitate learning.

This course has been written by healthcare content experts, has been peer reviewed and reviewed by a lawyer.

Target Audience

Nurses, midwives and managers

Learning Objectives

Participants will learn what constitutes a proper medical record the legal and ethical basis for the duty to maintain proper medical records and the patient safety elements in proper record keeping.

By the end of the course participants will:

  1. Know what a medical record is and what constitutes a proper medical record.
  2. Understand the legal and ethical consequences of failing to maintain proper medical records.
  3. Know what to include and what not to include in a medical record.
  4. Understand the risk management strategies to adopt in maintaining proper medical records.
  5. Understand how the courts may interpret medical records in the context of medico-legal claims.
  6. Be able to improve the quality of care through improved documentation.

Business Outcomes

This course forms an essential element in any comprehensive risk management and compliance learning package and is part of all clinicians' ongoing education requirements.