This interactive session will provide nurses and clinical team members with a comprehensive review of the legal, ethical, and professional standards surrounding documentation, communication, and patient safety. Using real-world scenarios involving Medical Holds and Epic Chat, participants will explore how nursing documentation influences clinical decision‑making, legal outcomes, and patient experience. Emphasis will be placed on accurate, objective, and legally defensible charting practices while avoiding bias, labeling, and assumptions. The session will also highlight the protections and expectations established under the Patient Safety and Quality Improvement Act (2005), ensuring participants understand their role in upholding a culture of safety and continuous quality improvement

Objectives: By the end of this session nurses will be able to:

• Understand the legalities of medical record usage
• Apply Standards of Nursing Practice in reporting and documentation
• Recognize and prevent biased documentation (i.e. language, assumptions and labeling)
• Understand how biased documentation can negatively influence patience care
• Describe the purpose and protections of the Patient Safety and Quality Improvement Act (2005)

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Learning Outcomes:

• Upon completion of this session, ≥80% of participants, as indicated by the post-evaluation survey will be able to demonstrate increased knowledge legal and ethical and professional standards surrounding documentation as in the post-evaluation.