LEGAL ISSUES IN PATIENT CARE

I. AVOIDING LEGAL PROBLEMS AS A PATIENT CARE GIVER

A. Elements of a Medical Malpractice Claim

B. Major Areas of Litigation

C. Ways to Avoid Litigation

II. PURPOSES OF DOCUMENTATION

A. Communication

B. Reimbursement

C. Legal Record

III. ELEMENTS OF EFFECTIVE DOCUMENTATION

A. Factual Information

B. Timeliness

C. Legibility

D. Approved Abbreviations

E. Completeness of Chart

F. Avoid Infighting

IV. MAKING CORRECTIONS

V. VERBAL COMMUNICATION AND VERBAL ORDERS

VI. COSIGNING ORDERS

VII. INCIDENT REPORTS

A. Purpose and Use

B. Documenting “Incidents”

VIII. SPECIAL ISSUES IN PATIENT CARE

A. Consultations

B. Discharge

C. Informed Consent

IX. PATIENT CONFIDENTIALITY

X. PRACTICAL CONSIDERATIONS

XI. ELECTRONIC RECORDS – LOOKING TO THE FUTURE