Chapter 1: Documentation and the Legal Environment
• The Health Care Malpractice Crisis
• Malpractice Defined
• Professional Negligence
• Ordinary Negligence Versus Professional Negligence
• Professional Standard of Care
• Inference and Presumptions of Health Professional Negligence
• Defenses to Healthcare Malpractice Negligence
• Vicarious Liability
• Liability for Patient Abandonment
• Bases of Liability Other then Negligence
• Other Settings and Consequences of Malpractice Actions
• Malpractice Trial Practice and Procedures
• The National Practitioner Data Bank
• Patient Care Documentation and Tort Reform Measures
Chapter 2: Clinical Documentation Methods and Management
• Purposes of Patient Care Documentation
• Contents of Patient Care Records
• Formats for Patient Care Documentation
• Risk Management Considerations for Effective Patient Care Documentation
Chapter 3: The Patient Care Record in Legal Proceedings
• Patient Treatment Records as Business and Legal Documents
• Patient-Focused Documentation: The Road Map to Quality Care and Effective Risk Management
• Creation and Maintenance of Patient Records
• Nonavailablility of Patient Care Records as Evidence of Spoliation
• Ownership of Patient Care Records
• Admission of the Patient Care Record in Court as Evidence
• Confidentiality of Patient Care Information
Chapter 4: Informed Consent Documentation Issues
• Legal Recognition of the Concept of Informed Consent
• When Is the Failure to Obtain Patient Informed Consent Legally Actionable?
• Disclosure Elements for Legally-Sufficient Patient Informed Consent
• Documenting a Patient’s “Informed Refusal”
• Clinical Models for Implementing Informed Consent
• Special Informed Consent Issues
• Informed Consent Documentation Formats
• Managed Care Informed Consent Documentation Issues
Chapter 5: Documentation Issues in Quality and Risk Management Activities
• Components of a Health Care Quality Management Program
• Confidentiality Considerations in Patient Care Quality Management
• Risk Management Patient Care Record Review
• Monitoring Informed Consent as a Quality Improvement Indicator
Chapter 6: Current Issues in Patient Care Documentation
• Advance Directives and the Patient Self-Determination Act
• Adverse Incident Documentation Issues
• Clinical Practice Guidelines as Evidence of the Legal Standard of Care
• Documenting the Care of Sexual Assault Patients
• Documenting the Use of Patient Restraints
• Electronic, Photographic, and Video-format Patient Care Records
• HIPAA
• Legal Issues Associated with Reimbursement Documentation
• Mandatory Reporting Requirements
• Patient Discharge Documentation
• Patient Noncompliance, Disengagement, and Abandonment
• Withdrawal of Life Support/DNR Guidelines
• Telehealth Documentation Issues
Back to top