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Doody's Review ServiceReviewer: Christopher J Hughes, PT, PhD, OCS, CSCS (Slippery Rock University)
Description: The focus of this book is on informing health professionals of the legal ramifications surrounding documentation. The previous edition was published in 2005.
Purpose: The author emphasizes the legal obligation of health professionals to properly and effectively document patient care activities. This update was needed to include recent requirements created by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and to address the implications of the electronic medical record.
Audience: This is an excellent resource for students, academicians teaching legal effects of documentation, and practicing healthcare professionals at all levels of experience. The author is a licensed physical therapist board certified in orthopedic physical therapy as well as a health care attorney and educator. He has also written extensively on the topics of health law and ethics.
Features: Six chapters cover topics related to risk management, informed consent, legal proceedings and the healthcare record, and methods and management of clinical documentation. The new information on the impact of HIPAA is very timely. The author has filled the book with several case study examples and offers a helpful glossary of terms and also cites relevant legal proceedings. His writing is easy to read and holds the readers interest. Even though the book is less than 200 pages, it offers a wealth of information.
Assessment: To remain current, the author has compiled an excellent new edition. The book is unique in the field and is a "must have" book for the student and practicing clinician. The information presented here can literally determine the success of a clinician's career in terms of adhering to proper procedures for documentation and avoiding adverse litigation.