Legal Aspects of Documenting Patient Care

Note: Supplemental materials are not guaranteed with Rental or Used book purchases.

ISBN: 9780834205499 | 0834205491
Cover: Hardcover
Copyright: 1/1/1994

Buy New

Usually Ships in 3-5 Business Days

$68.95

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.

Preface	p. ix
About the Author	p. xiii
Documentation and the Legal Environment	p. 1
The Health Care Malpractice Crisis	p. 1
Malpractice Defined	p. 3
Professional Negligence	p. 5
Ordinary Negligence Versus Professional Negligence	p. 6
Professional Standard of Care	p. 6
Res Ipsa Loquitur: Inferences and Presumptions of Health Professional Negligence	p. 8
Defenses to Health Care Malpractice Actions	p. 9
Vicarious Liability	p. 10
Liability for Patient Abandonment	p. 13
Bases of Liability Other than Negligence	p. 15
Other Settings and Consequences of Malpractice Actions	p. 16
Malpractice Trial Practice and Procedures	p. 17
The National Practitioner Data Bank	p. 20
Patient Care Documentation and Tort Reform Measures	p. 21
Conclusion	p. 22
References and Suggested Readings	p. 23
Review Case Studies	p. 24
Discussion: Review Case Studies	p. 24
Clinical Documentation Methods and Management	p. 27
Introduction	p. 27
Purposes of Patient Care Documentation	p. 29
Contents of Patient Care Records	p. 31
Formats for Patient Care Documentation	p. 31
Risk Management Considerations for Effective Patient Care Documentation	p. 36
Conclusion	p. 61
Suggested Readings	p. 62
Review Case Studies	p. 63
Discussion: Review Case Studies
Additional Examples of Patient Care Documentation Formats	p. 64
Examples of Acceptable Techniques for Patient Care Documentation Error Correction	p. 67
The Patient Care Record in Legal Proceedings	p. 73
Patient Treatment Records as Business and Legal Documents	p. 73
Patient-Focused Documentation: The Road Map to Quality Care and Effective Risk Management	p. 74
Creation and Maintenance of Patient Records	p. 75
Nonavailability of Patient Care Records as Evidence of Spoliation	p. 76
Ownership of Patient Care Records	p. 81
Admission of the Patient Care Record in Court as Evidence	p. 84
Confidentiality of Patient Care Information	p. 89
Conclusion	p. 94
Notes and References	p. 95
Suggested Readings	p. 96
Review Case Studies	p. 97
Discussion: Review Case Studies	p. 97
Informed Consent Documentation Issues	p. 99
Introduction	p. 99
Legal Recognition of the Concept of Informed Consent	p. 100
Evolution of the Law of Informed Consent	p. 101
When Is the Failure to Obtain Patient Informed Consent Legally Actionable?	p. 103
Disclosure Elements for Legally-Sufficient Patient Informed Consent	p. 104
Documenting a Patient's "Informed Refusal"	p. 106
Clinical Models for Implementing Informed Consent	p. 107
Special Informed Consent Issues	p. 108
Informed Consent Documentation Formats	p. 114
Managed Care Informed Consent Documentation Issues	p. 117
Conclusion	p. 118
Notes and References	p. 119
Suggested Readings	p. 119
Review Case Studies	p. 120
Discussion: Review Case Studies	p. 120
Review Activity	p. 121
Documentation Issues in Quality and Risk Management Activities	p. 123
Introduction	p. 123
Components of a Health Care Quality Management Program	p. 125
Confidentiality Considerations in Patient Care Quality Management	p. 128
Risk Management Patient Care Record Review	p. 129
Monitoring Informed Consent as a Quality Improvement Indicator	p. 130
Conclusion	p. 132
Notes	p. 133
Suggested Readings	p. 133
Review Activities	p. 134
Example of a Peer Review Work Sheet for Evaluation of Interdisciplinary Primary Health Care Professionals in a Rehabilitation Setting	p. 135
Example of a Patient Satisfaction Survey	p. 136
Current Issues in Patient Care Documentation	p. 137
Advance Directives and the Patient Self-Determination Act	p. 137
Adverse Incident Documentation Issues	p. 139
Clinical Practice Guidelines as Evidence of the Legal Standard of Care	p. 141
Documenting the Care of Sexual Assault Patients	p. 142
Documenting the Use of Patient Restraints	p. 143
Electronic, Photographic, and Video-format Patient Care Records	p. 144
HIPAA	p. 147
Legal Issues Associated with Reimbursement Documentation	p. 156
Mandatory Reporting Requirements	p. 159
Patient Discharge Documentation	p. 161
Patient Noncompliance, Disengagement, and Abandonment	p. 162
Withdrawal of Life Support/DNR Guidelines	p. 163
Telehealth Documentation Issues	p. 164
Conclusion	p. 165
Notes	p. 165
Suggested Readings	p. 167
Review Case Studies	p. 168
Discussion: Review Case Studies	p. 169
Review Activities	p. 170
Epilogue	p. 171
Glossary of Terms	p. 173
Table of Contents provided by Ingram. All Rights Reserved.

Please wait while the item is added to your bag...

FREE SHIPPING

Amazon no longer offers textbook rentals. We do!

Legal Aspects of Documenting Patient Care

Summary

Author Biography

Table of Contents

Supplemental Materials