Legal aspects of documenting patient care

by Ronald W. Scott

Publisher: Aspen Publishers in Gaithersburg, Md

Written in English
Cover of: Legal aspects of documenting patient care | Ronald W. Scott
Published: Pages: 221 Downloads: 247
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Places:

  • United States.

Subjects:

  • Medical records -- Law and legislation -- United States,
  • Medical care -- Law and legislation -- United States,
  • Medical records -- Management

Edition Notes

Includes bibliographical references and index.

StatementRonald W. Scott.
Classifications
LC ClassificationsKF3827.R4 S385 2000
The Physical Object
Paginationxv, 221 p. :
Number of Pages221
ID Numbers
Open LibraryOL50799M
ISBN 100834216302
LC Control Number99055592
OCLC/WorldCa42708069

7. Explain nursing documentation requirements for specific aspects of care, including critical diagnostic results, medications, non-conforming patient behavior, pain, patient and family involvement in care, restraints, and prevention of falls, infections, pressure ulcers, and suicide. 8. The medical record is a legal document and is used to protect the patient as well as the professional practice of those in healthcare. Documentation of the care you give is proof of the care you provide. Any attorney or risk manager should be able to reconstruct the . Legal Aspects of Health. Information. Management. EXERCISE Legal and Regulatory Terms. 1. T c. Generated at or near the time of patient care d. Maintained in the regular course of business Documenting the method of operation used to create an electronic medical record g. Documenting the method and circumstances of preparing the. Buy Legal, Ethical, And Practical Aspects Of Patient Care Documentation: A Guide For Rehabilitation Professionals (Legal Aspects of Documenting Patient Care for Rehabilitation Professionals) by Ron W. Scott () by Ron W. Scott (ISBN:) from Amazon's Book Store. Everyday low prices and free delivery on eligible mcgivesback.com: Ron W. Scott.

mcgivesback.com [email protected] REPORTING & DOCUMENTING: CLIENT CARE © May be copied for use within . Jan 19,  · One of the tasks that a nurse must accomplish for every shift is their documentation of the patient’s mcgivesback.com is considered a legal document that can be used in every court of law. From the traditional handwritten notes until today’s high technology hospital documentation, the important aspects should never be forgotten. The legal aspects of nursing have an impact on the manner in which care is delivered to patients by nurses. Legal concerns shape the environment in which nursing is practiced and determine how documents are kept or shared. Ultimately, nurses and the nursing care they provide are judged based on a legal definition for the standard of care for. 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 mcgivesback.com: Ron W. Scott.

Medical recording needs the concerted effort of a number of people involved in patient care. The doctor is the prime person who has to oversee this process and is primarily responsible for history, physical examination, treatment plans, operative records, consent forms, medications used, referral papers, discharge records, and medical certificates. Several other aspects of the patient visit should also be documented. Pharmacists generally request that patients fill out a medical history form and a com-plete medication list at the initial visit for patient care Medication Therapy Management Services: Documenting Pharmacy-Based Patient Care Services 1. Clinical responsibilities of the medical office - assisting the physician with patient related care Preparing patients for examination and treatment, routine procedures and diagnostic testing HIPAA, patient confidentiality, legal aspects of healthcare and regulatory patient care issues. AU – HET Education & Training Plans Page 1 of 9. Ensure confident clinical decisions and maximum reimbursement in a variety of practice settings such as acute care, outpatient, home care, and nursing homes with the only systematic approach to documentation for rehabilitation professionals! Revised and expanded, this hands-on textbook/workbook provides a unique framework for maintaining evidence of treatment progress and patient outcomes .

Legal aspects of documenting patient care by Ronald W. Scott Download PDF EPUB FB2

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 â€" from intake through mcgivesback.com: Ron W.

Scott. Legal aspects of documenting patient care. [Ronald W Scott] Home. WorldCat Home About WorldCat Help. Search. Search for Library Items Search for Lists Search for Contacts Search for a Library.

Create lists, bibliographies and reviews: or Search WorldCat. Find items in libraries near you CreativeWork, schema:Book. Overview of the legal environment and documentation-related health care malpractice issues --Clinical documentation: methods and management --The patient care record in legal proceedings --Informed consent documentation issues --Documentation issues in patient care quality and risk management activities --Example of a peer review work sheet.

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 mcgivesback.com: $ mcgivesback.com: legal aspects of health.

Skip to main content. Try Prime All Go Search EN Hello, Sign in Account & Lists Sign in Account & Lists Orders Try Prime. Medical Record Documentation and Legal Aspects Appropriate to Nursing Assistants is a 1 hour cnaZone continuing education course for CNAs. Patient care documentation created by the rehabilitation skilled have to be correct, complete, concise, goal, well timed, and expeditiously communicated to different professionals on the well being care staff.

Legal Aspects of Documenting Patient Care for Rehabilitation Professionals, Third Legal aspects of documenting patient care book, supplies a complete overview of authorized.

Explain nursing documentation requirements for specific aspects of care, including critical diagnostic results, medications, non-conforming patient behavior, pain, patient and family involvement in care, restraints, and prevention of falls, infections, pressure ulcers, and suicide.

Patient documentation frequently is used by professionals who are not directly involved with the patient’s mcgivesback.com patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient’s care to use the.

The author addresses legal aspects of patient care documentation pertinent to treatment, informed consent, discharge, and adverse incidents. He first presents a capsule overview of medical malpractice and, thereafter, explores formats for notation required to meet a legal standard of mcgivesback.com: $ Patient care documentation created by the rehabilitation professional must be accurate, comprehensive, concise, objective, timely, and 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. Nov 04,  · Do you want to remove all your recent searches. All recent searches will be deleted.

The failure of the nurse to monitor the patient for an appropriate response to medication, side effects or toxicity can result in harm to the patient. Following the physician's orders does not protect the nurse from legal action if or when the patient is harmed.

It is the nurse's responsibility to. "Chapter 7. Legal Issues in the Medical Record." Effective Documentation for Physical Therapy Professionals, obtained and shared, the care rendered, the role of the healthcare provider, and whether the professional and legal standards of care were met or breached.

The significance of documenting patient care accurately, comprehensively. 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.

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.

The Journal of Continuing Education in Nursing | Nursing Documentation: A Nursing Process Approach RW. Iyer & N.H. Camp New York: Mosby-Year Book, Inc.mcgivesback.comg Documentation: A Author: Mary Jane Ferrell. Home > January - Volume 22 - Issue 2 > Legal Aspects of Documenting Patient Care (Second edition) Log in to view full text.

If you're not a subscriber, you can. Personal information may be shared with parents, spouse, legal guardians, or those involved in care of the client without a specific release, but the individual should to carelessness in documenting has little credibility. Further, if a medication that is not The use of the term “patient” or “client” should be.

Regardless of the method, the nurse has a legal and ethical obligation to respond to the request for care. In general, the nurse should see the patient to evaluate health needs and determine the level of care required.

If the communication is from the officer to the nurse. The book is aimed at all health professionals who care for the patient, and for patient service managers, patient groups, relatives and anybody who is interested in understanding the law relating to patient confidentiality.

The book includes case studies throughout. Free 2-day shipping. Buy Legal, Ethical, and Practical Aspects of Patient Care Documentation: A Guide for Rehabilitation Professionals at mcgivesback.comnd: Jones & Bartlett Publishers.

Start studying Medical law & ethics chp 7 session 9. Learn vocabulary, terms, and more with flashcards, games, and other study tools.

The Legal Medical Record is a subset of the Designated Record Set and is the record that will be released for legal proceedings or in response to a request to release patient medical records.

The Legal Medical Record can be certified as such in a court of law. Designated Record Set (“DRS”). Many aspects of prehospital medicine fall squarely into the category of science. Providers use evidence-based data to make the best choice regarding treatment, or base patient management on.

The Joint Commission released a revised set of standards on patient-centered communication in The standards outlined "effective communication, cultural competence, and patient- and family-centered care as important components of safe, quality care" (The Joint Commission,p.

health care personnel must respect the confidentiality of the patient's record. the patient's bill of rights and the law guarantee that the patient's medical information will be kept private, unless the information is needed in providing care or the patient gives permission for others to see it.

Documenting for Practice and Liability. Did you know that the medical record might be the only evidence presented in a lawsuit. This is because the patient’s medical record is the most powerful tool attorneys, legal experts, and expert witnesses use to examine the type of.

Health care records promote patient safety, continuity of care across time and care settings, and support the transfer of information when the care of a patient / client is transferred eg.

at clinical handover, during escalation of care for a deteriorating patient and transfer of a patient / client between settings. Key definitions Attending. 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.

2 Improving Nursing Documentation and Reducing Risk CPro Chapter 1 include QSEN and the NOF core competencies. The NOF defines communication as the ability to “interact effectively with patients, families, and colleagues, fostering mutual respect and shared deci-sion-making, to enhance patient satisfaction and health outcomes.”.As a nurse it has become an important necessity to be aware of the legal aspects associated with caring and helping people in the health industry today.

Unfortunately, the more and more negligence cases there are the less and less people want to get into the health care field fearing legal aspects and the inevitable law suites. The first nursing law created was that of nursing registration in.Feb 08,  · After all my years in nursing and some legal training, there are some fundamental rules every nurse should follow when documenting in a patient record.’ 1.

Always be truthful. Do not document that you did something when you did not do it. 2. Never.