“No matter how skilled or experienced you are, inaccurate or incomplete nursing documentation can mean serious trouble for your patients – and for you if you’re ever involved in a lawsuit.” Austin, Nursing2021. Many nurses who have had to testify in a deposition or trial have realized that their clinical documentation did not paint as accurate or complete a picture as they thought it did when they wrote it. Understanding both the regulatory requirements and the legal aspects of documentation is critical in order to consistently complete medical record entries that prove that the standard of care was met.

In the CMS State Operations Manual (SOM) for tag F 842, the Federal Regulation §483.70(i) and §483.70(i)(1) Medical records stipulate the following:

In accordance with accepted professional standards and practices, the facility must maintain medical

Records on each resident that are –

        • Complete;
        • Accurately documented;
        • Readily accessible; and
        • Systematically organized

The CMS SOM provides the following guidance for these regulations:

The medical record shall reflect a resident’s progress toward achieving their person-centered plan of care objectives and goals and the improvement and maintenance of their clinical, functional, mental and psychosocial status.


The medical record must also reflect the resident’s condition and the care and services provided across all disciplines to ensure information is available to facilitate communication among the interdisciplinary team.

 Take Action Toward Improving Your Documentation

Make plans to join us for the April webinar:  Legal Aspects of Documentation.  This session, which is part of the monthly 2021 Cultivating LTC Leaders series, will review each of the 4 components required to meet the Medical Records regulation.  It will also explore best practices for implementing and/or improving critical nursing documentation and for understanding the role of interdisciplinary team members in communicating through documentation.

As electronic medical records become more prevalent in health care, tips and strategies for avoiding some of the common pitfalls associated with EMR, and the regulatory required EMR policies will be discussed.

Of course, no documentation strategy is complete without a QAPI component for monitoring and guiding of the IDT when corrective action or revisions are needed.  The Legal Aspects of Documentation webinar will also provide sample documentation audit tools to utilize as part of a thorough QAPI program.

The care you take in documenting could be your best defense in supporting the care you provided.

Join us April 6 or April 7 for a 1-hour webinar focused on Legal Aspects of Documentation as part of the monthly Cultivating LTC Leaders series focused on identifying and mitigating facility risks and gaining practical skills to address critical industry challenges.


Blog by Janine Lehman, RN, RAC-CT, CLNC, Proactive Medical Review

Click here to learn more about Eleisha and the rest of the Proactive team.