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Tabla de contenidos provista por Syndetics

• Preface(p. ix)
• About the Author(p. xiii)
• Chapter 1 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)
• Chapter 2 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
• Appendix 2-A Additional Examples of Patient Care Documentation Formats(p. 64)
• Appendix 2-B Examples of Acceptable Techniques for Patient Care Documentation Error Correction(p. 67)
• Chapter 3 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)
• Chapter 4 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)
• Chapter 5 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)
• Appendix 5-A Example of a Peer Review Work Sheet for Evaluation of Interdisciplinary Primary Health Care Professionals in a Rehabilitation Setting(p. 135)
• Appendix 5-B Example of a Patient Satisfaction Survey(p. 136)
• Chapter 6 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)

Notas de autor provistas por Syndetics

Ronald W. Scott, EdD, LLM, PT is a clinical physical therapist with Health South-Crestway, San Antonio, Texas