Legal Aspects of Documenting Patient Care.

Scott RW. Gaithersburg, MD 20878, Aspen Publishers Inc, 1994, hardback, 242 pp, S52.

The major focus of this book is to encourage a risk-management approach to clinical documentation. The author promotes this approach to foster the clinician to be objective, precise, unambiguous, and timely in his or her documentation for the medical record. Those who stand to benefit most from this book would be rehabilitation professionals, health care practitioners, health care attorneys, and others who are involved with the documentation process, such as quality management professionals, medical records administrators, and risk management professionals.

The various chapters are well coordinated. The author's treatment of the subject matter is detailed enough to meet the needs of the reader, but not so detailed and complex as pure legal texts tend to be. The depth and coverage of the writing are sufficient in creating an understanding of the writer's purpose in each section. The strong overview in chapter 1 benefits the reader tremendously by presenting a clear, understandable approach to basic legal principles that apply to the following chapters.

The content is very informative, accurate, and current. Even the recent changes to the joint Commission on Accreditation of Healthcare Organizations' Accreditation Manual (1994) are included and concisely presented. Like the author's previous work, the material is written in a clear, applicable, and comprehendible manner for the physical therapy clinician by a physical therapy clinician/jurist. The information cited is appropriately supported, with an extensive compilation of endnotes, references, and suggested readings.

The book's six chapters follow a logical progression. Subtitles in the chapters, variations in print style, and blocked-off information allow for easier reading and clearly distinguish pertinent information, examples, and exhibits.

Each chapter ends with review questions and activities that stimulate thought related to the chapter: suggested answers and discussion follow. Numerous appendixes provide excellent examples in associated areas. A well-developed glossary of legal terms and an appendix for some examples of approved abbreviations are located at the end of the book. A table of cases and an index are also useful features of the book.

The relevance of this book to physical therapy practice is very clear. An ever-growing litigious society and the increased independence of the physical therapy practitioner demand clear and precise documentation. Every physical therapy practitioner would benefit from these writings. It would also be an excellent supplemental text for administration-related courses in the physical therapy curricula and also as a worthwhile reference text for every physical therapy department and practice. Those who are involved in malpractice defense of physical therapy cases would likewise benefit from several of the chapters. Although best serving the physical therapy clinician, other health care practitioners would also be well served.

Joseph W Rusinowski, Jr, PT Imperial Point Medical Center Ft Lauderdale, Fla

Mr Rusinowski is director of fitness and rehabilitation services at Imperial Point Medical Center. His background and special interests are in hospital clinical practice management, health care law, and ethics.