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

Legal Aspects of Documenting Patient Care for Rehabilitation Professionals, Third Edition, provides a comprehensive overview of legal issues related to everyday patient care clinical documentation. This text presents extensive coverage of the electronic medical record, the HIPAA Privacy Rule and incident reporting, among other focused topics.

Chapter1 Patient Care Documentation within the Legal Environment
Chapter2 Clinical Patient Care Documentation Methods and Management
Appendix2-A Additional Examples of Patient Care Documentation Formats
Appendix2-B Examples of Acceptable Techniques for Patient Care Documentation Error Correction
Chapter3 The Patient Care Record in Legal Proceedings
Chapter4 Patient Care Record Informed Consent Documentation Issues
Chapter5 Patient Care Documentation and Clinical Quality-Risk Management Programs and Initiatives
Appendix5-A Example of a Peer Review Work Sheet for Evaluation of Interdisciplinary Primary Health Care Professionals in a Rehabilitation Setting
Appendix5-B Sample Patient Satisfaction Survey
Chapter6 Current Issues in Patient Care Documentation