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

Author(s): Ron W. Scott, PT, JD, EdD, LLM, MSBA
  • ISBN-13: 9780763799106
  • ISBN-10:0763799106
  • Paperback    276 pages      © 2013
Price: $91.95 US List
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Doody's Review Service: Score: 97, 4 Stars!

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. This resource thoroughly covers the basics of documentation and includes many exemplars, cases, and forms, as well as a sample abbreviations used in rehabilitation settings. 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. Even after graduation, this text is perfect for ready reference in the clinic.


  • Thoroughly updated  content and references
  • Coverage of patient informed consent documentation issues
  • Focus on electronic medical records (EMRs)
  • Examination of the patient care record as a legal document, used in legal proceedings
  • Exemplars showing purposes, methods, and techniques of patient care documentation
  • Case examples in the ethical aspects of patient care documentation
  • Documentation formats and activities
  • Documentation errors and suggestions
  • Background information on the litigation environment written by a health law attorney
  • Focus on Ethics vignettes

Applicable Courses

Patient Care Documentation

Professional Issues

Chapter  1  Patient Care Documentation within the Legal Environment
Chapter  2  Clinical Patient Care Documentation Methods and Management
  Appendix  2-A  Additional Examples of Patient Care Documentation Formats
  Appendix  2-B  Examples of Acceptable Techniques for Patient Care Documentation Error Correction
Chapter  3  The Patient Care Record in Legal Proceedings
Chapter  4  Patient Care Record Informed Consent Documentation Issues
Chapter  5  Patient Care Documentation and Clinical Quality-Risk Management Programs and Initiatives
  Appendix  5-A  Example of a Peer Review Work Sheet for Evaluation of Interdisciplinary Primary Health Care Professionals in a Rehabilitation Setting
  Appendix  5-B  Sample Patient Satisfaction Survey
Chapter  6  Current Issues in Patient Care Documentation

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.          

Additional Titles by this Author
  • "This is a good guide to documentation standards for outpatient clinics and hospital rehabilitation departments, among others. It illustrates the consequences of our failure to communicate effectively and accurately in our documentation and how it can be career changing under the scrutiny of the legal system. It is each therapist's professional responsibility to document effectively and know the highest standards of current practice. This book provides the guidelines for these standards. The updated edition is needed in the evolving landscape of documentation expectations."

    ~ Monique Serpas, DPT, HealthReach Rehabilitation Services (for Doody's Review Service. Score: 97, 4 Stars!)

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