Legal, Ethical, and Practical Aspects of Patient Care Documentation: A Guide for Rehabilitation Professionals / Edition 4

by Ron W. Scott

Overview

Legal, Ethical, and Practical Aspects of Patient Care Documentation: A Guide for Rehabilitation Professionals, Fourth Edition, is the only text to integrate coverage of the legal responsibilities of rehabilitation professionals with basic, essential advice on how to effectively document patient care activities – from intake through discharge. This resource thoroughly covers the basics of documentation and includes many exemplars, cases, and forms, as well as a sample abbreviations used in rehabilitation settings. Legal, Ethical, and Practical Aspects of Patient Care Documentation, Fourth Edition covers all the bases – from ethics, to practical aspects of patient care documentation, to relevant and salient legal implications and illustrative case examples that will help students excel in practice. Even after graduation, this text is perfect for ready reference in the clinic!FEATURES

All updated materials and references
A chapter on patient informed consent documentation issues
Focus on electronic medical records (EMRs)
The patient care record, as a legal document, used in legal proceedings
Exemplars showing purposes, methods, and techniques of patient care documentation
Case examples in the ethical aspects of patient care documentation
Documentation formats
Documentation activities
25 documentation errors and suggestions
Background information on the litigation environment written by a health law attorney
Focus on Ethics vignettes
Extensive reference lists
Universal coverage of health disciplines

Product Details

ISBN-13:	9780763799106
Publisher:	Jones & Bartlett Learning
Publication date:	11/28/2011
Edition description:	4
Pages:	276
Product dimensions:	5.90(w) x 8.90(h) x 0.70(d)

About the Author

Ron Scott has been a health professional (LPN, OR technician, PT, clinical manager and administrator) since 1970, an attorney-mediator since 1983, and an academician since 1985. One of his principal passions is helping health care professionals and organizations minimize their clinical liability risk exposure through effective patient care documentation that is accurate, communicative, complete, concise, objective and timely. Ron is the author of 13 texts and more than 100 health law-related articles. He is a Professor at Rocky Mountain University of Health Professions (OT, nursing, PT) and is adjunct faculty at Husson University, Webster University, the University of Indianapolis and the University of Montana.

Table of Contents

Chapter 1 Patient Care Documentation within the Legal Environment
Chapter 2 Clinical Patient Care Documentation Methods and Management
Appendix 2-A Additional Examples of Patient Care Documentation Formats
Appendix 2-B Examples of Acceptable Techniques for Patient Care Documentation Error Correction
Chapter 3 The Patient Care Record in Legal Proceedings
Chapter 4 Patient Care Record Informed Consent Documentation Issue s
Chapter 5 Patient Care Documentation and Clinical Quality-Risk Management Programs and Initiatives
Appendix 5-A Example of a Peer Review Work Sheet for Evaluation of Interdisciplinary Primary Health Care Professionals in a Rehabilitation Setting
Appendix 5-B Sample Patient Satisfaction Survey
Chapter 6 Current Issue s in Patient Care Documentation

Editorial Reviews

Reviewer: Monique Serpas, PT, DPT, OCS (Southeast Louisiana Veterans Health Care System)
Description: This book describes professional standards for documentation, use of documentation in legal proceedings, ethical considerations in documentation, and strategies to minimize risk of malpractice liability for rehabilitation professionals. It provides useful and basic guidance in a variety of clinical scenarios from informed consent prior to manual therapy to documenting medical necessity for third-party reimbursement. The previous edition was published in 2005.
Purpose: The purpose is to give rehabilitation professionals and students a framework for meeting the basic standards of documentation to improve the quality of patient care and reduce the risk of adverse legal consequences. The author achieves this through defining malpractice and liability, describing common documentation pitfalls, discussing documentation for a wide variety of clinical scenarios, and illustrating the legal and ethical consequences of poor documentation.n.
Audience: The author states the book is written to guide health professionals and students. Although the documentation examples are written mainly from the perspectives of PTs and MDs, the book can be helpful for other professions in rehabilitation settings. It is a good reference for new professionals, clinical managers, and any other people with the responsibility of risk management.
Features: Each of the six chapters contains a summary as well as a focus on ethics discussion, references and suggested readings, review case studies, and discussions of the review case studies. The chapter on "Problems, Errors, and Suggestions" is most immediately applicable to therapists and provides specific examples of common documentation mistakes, their legal and ethical consequences, and strategies to prevent them. Time constraints on orthopedic physical therapists are ever-present in the effort to provide the most cost-effective care, but, as the author points out, they must also realize that the quality of documentation is held to higher standards than ever before. The author provides helpful examples of incorrect documentation strategies, as well as correct ones, and, where necessary, a framework for documentation forms. These forms, including incident reports, informed consent, release of records, peer review worksheets, and HIPAA privacy notification, provide practical guidelines. The glossary provides quick descriptions of common legal terms that are devoid of complicated legal jargon, which makes them easier to understand. The author references court cases in certain parts of the book, and more such references as they relate to inadequate documentation would further motivate readers to make recommendations a priority.
Assessment: This is a good guide to documentation standards for outpatient clinics and hospital rehabilitation departments, among others. It illustrates the consequences of our failure to communicate effectively and accurately in our documentation and how it can be career changing under the scrutiny of the legal system. It is each therapist's professional responsibility to document effectively and know the highest standards of current practice. This book provides the guidelines for these standards. The updated edition is needed in the evolving landscape of documentation expectations.

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