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.
