Legal Aspects of Documenting Patient Care for Rehabilitation Professionals

Because communication among health care professionals can mean the difference between patient life and death, clear and effective patient care documentation is as important as the delivery of care itself. The rehabilitation professional faces formidable documentation responsibilities.  Patient care documentation created by the rehabilitation professional must be accurate, comprehensive, concise, objective, and timely. In an interdisciplinary health care environment, documentation must also be expeditiously communicated to other professionals on the health care team.

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.

Legal Aspects of Documenting Patient Care for Rehabilitation Professionals, Third Edition guides the rehabilitation professional through what can be a bewildering and overwhelming range of documentation duties and responsibilities.

Chapter coverage includes:

• The Legal Environment
• Documentation Methods & Management
• The Patient Care Record in Legal Proceedings
• Informed Consent Documentation Issues
• Documentation in Quality and Risk Management Activities
• Current Issues (including HIPAA and advance directives)

The book also includes and extensive glossary of terms and abbreviations.

Ron W. Scott, PT, JD, EdD, LLM, MSBA

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.