Legal Aspects of Documenting Patient Care / Edition 1

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Overview

This easy-to-use reference takes a risk management approach to patient care documentation promoting optimal quality care by showing clinicians how to be objective, precise, unambiguous, and timely when they document treatment-related matters. Written in a lay person's language, this essential resource provides how-to guidelines along with sample model forms to help the clinician cope with the complex legal issue of patient documentation.

The book contains black-and-white illustrations.

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Editorial Reviews

Doody's Review Service
Reviewer: Max Douglas Brown, JD (Rush University Medical Center)
Description: The book promotes a risk management approach to patient care documentation.
Purpose: The author addresses legal aspects of patient care documentation pertinent to treatment, informed consent, discharge, and adverse incidents. He first presents a capsule overview of medical malpractice and, thereafter, explores formats for notation required to meet a legal standard of care.
Audience: The title implies a subject matter of interest to a broad spectrum of health care professionals; however, the author, who is a physical therapist and lawyer, directs the content to a more narrow audience of physical therapists and nurse practitioners. Examples of documentation issues are predominantly grounded in physical therapy cases.
Features: Notwithstanding the limited usefulness of the material, the book contains many interesting features. Boxes that contain key concepts and narrative summaries aid the reader throughout the text. Each chapter concludes with suggested reading, review questions, and model forms. Hypothetical cases appear in each chapter. End notes and references are useful; however, citations tend to be journal articles discussing legal cases rather than referring to cases themselves. Where cases are cited, they are usually physical therapy cases.
Assessment: The content of the book is more limited than that which the title implies. The documentation suggestions offered (e.g., identify the patient, note the date and time of treatment, document in a timely manner, document objectively, and sign treatment entries) tend to be fairly obvious. A general admonition repeated in several of the situations is to provide "careful and thorough documentation." This approach of "more is better" tends to foster exactly what the book seeks to avoid—defensive medicine.
Max Douglas Brown
The book promotes a risk management approach to patient care documentation. The author addresses legal aspects of patient care documentation pertinent to treatment, informed consent, discharge, and adverse incidents. He first presents a capsule overview of medical malpractice and, thereafter, explores formats for notation required to meet a legal standard of care. The title implies a subject matter of interest to a broad spectrum of health care professionals; however, the author, who is a physical therapist and lawyer, directs the content to a more narrow audience of physical therapists and nurse practitioners. Examples of documentation issues are predominantly grounded in physical therapy cases. Notwithstanding the limited usefulness of the material, the book contains many interesting features. Boxes that contain key concepts and narrative summaries aid the reader throughout the text. Each chapter concludes with suggested reading, review questions, and model forms. Hypothetical cases appear in each chapter. End notes and references are useful; however, citations tend to be journal articles discussing legal cases rather than referring to cases themselves. Where cases are cited, they are usually physical therapy cases. The content of the book is more limited than that which the title implies. The documentation suggestions offered (e.g., identify the patient, note the date and time of treatment, document in a timely manner, document objectively, and sign treatment entries) tend to be fairly obvious. A general admonition repeated in several of the situations is to provide "careful and thorough documentation." This approach of "more is better" tends to foster exactly what the book seeks toavoid--defensive medicine.
Booknews
Adopting a risk management approach to the documentation of patient care, this reference provides an overview of the legal environment and malpractice issues; methods and management; legal proceedings; informed consent issues; patient care quality and risk management activities; and current issues. Includes a glossary and an example of an approved abbreviation list for a rehabilitation center. Annotation c. Book News, Inc., Portland, OR (booknews.com)

2 Stars from Doody
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Product Details

  • ISBN-13: 9780834205499
  • Publisher: Wolters Kluwer Law & Business
  • Publication date: 1/27/1994
  • Edition description: Older Edition
  • Edition number: 1
  • Pages: 242

Table of Contents

Contents: An Overview of the Legal Environment and Malpractice Issues for Health Care Professionals
• Clinical Documentation: Methods and Management
• The Patient Treatment Record in Legal Proceedings
• Informed Consent: Substance and Process
• Continuous Quality Improvement: Monitoring, Evaluating, and Documenting Important Aspects of Patient Care
• Adverse Incidents, Abandonment, and Other Special Circumstances
• Epilogue

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