History Taking, Examination, and Record Keeping in Emergency Medicine / Edition 1 available in Paperback
- Pub. Date:
- Oxford University Press, USA
Good records are essential in Accident & Emergency medicine for adequate clinical care as well as for medico-legal reasons.
This book explains the reasons for keeping good records and describes how A&E records should be kept both in general terms and emphasizes the essential information to be recorded with different mechanisms of injury and in different anatomical sites. Some proformas for collecting information on specific injuries are given and there are many examples of appropriate notes.
Table of Contents
Reasons for good notekeeping
Basic pattern of notes
X-rays and other investigations
Letters to the GP
General points joints bones including fractures non traumatic problems
Parts of the body head face neck spine chest abdomen shoulder elbow wrist hand child not using upper limb hip knee ankle foot child not weight bearing or limping
Road Traffic Accidents
Deliberate self harm
Nursing notes by A.M. Jenkin BSc, RGN