Medical Record Documentation and Legal Aspects Appropriate to Nursing Assistants (CNA001)

Certified Nursing Assistant


Documentation is needed to provide high quality patient care. This course presents general documentation principles. Your facility has specific standards for documentation. Whether your facility uses computers for documentation or paper forms, you will find the same principles apply. Documentation can be used as legal evidence to defend you and your facility. It can protect against allegations of malpractice, negligence, or failure to meet standards of care. It also is a key communication tool to other care providers.

  • Objective
  • Standards of Documentation
  • Legal Implications
  • Survey Preparation
  • Principles of Good Documentation for Medical Records
  • Mobility & Level of Assistance
  • Conclusion
  • Medical Record Documentation Post Test
  • Medical Record Documentation Post Course Survey
Completion rules
  • All units must be completed
  • Leads to a certification with a duration: 2 years