History Taking, Examination, and Record Keeping in Emergency Medicine

Paperback | October 1, 1995

byH. R. Guly

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Good record keeping is essential in medicine, a point often stressed by the defence organizations. A and E records are frequently very bad - which may cause medicological problems as well as impairing effective patient care. The reason is inexperience. This book explains what it isimportant to record (and why) and gives examples.Good records are essential in A and E. This book explains the reasons for keeping good records and describes how A and E records should be kept, both in general terms nad emphasizing the essential information to be recorded with different mechanisms of injury and in different anatomical sites.Some performas for collecting information on examination, especially orthopaedic and neurological examination, but none which specifically covers record-keeping or even discusses it other than to stress its importance. There are pamphlets for medical students often provided by individual medicalschools, but these just cover general medicine and surgery.

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Good record keeping is essential in medicine, a point often stressed by the defence organizations. A and E records are frequently very bad - which may cause medicological problems as well as impairing effective patient care. The reason is inexperience. This book explains what it isimportant to record (and why) and gives examples.Goo...

Henry R. Guly is at Derriford Hosital, Plymouth.

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Format:PaperbackDimensions:240 pages, 8.5 × 5.43 × 0.55 inPublished:October 1, 1995Publisher:Oxford University Press

The following ISBNs are associated with this title:

ISBN - 10:019262461X

ISBN - 13:9780192624611

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Extra Content

Table of Contents

IntroductionReasons for good notekeepingBasiuc pattern of notesHistoryExaminationX-rays and other investigationsDiagnosisPractical proceduresDrugsAdviceLetters to the GPGeneral pointsjointsbones including fractureswoundsnon traumatic problemsParts of the bodyheadfaceneckspinechestabdomenshoulderelbowwristhandchild not using upper limbhipkneeanklefootchild not weight bearing or limpingBurnsRoad Traffic AccidentsMajor TraumaDeliberate self harmNursing notes by A.M. Jenkin B Sc, RGN

Editorial Reviews

`This little book contains wise tips for physicians and nurses who work in emergency departments. This book is seeded with tips about understanding the patient's agenda while attempting to make an accurate diagnosis. New students will benefit from early exposure to this wisdom, and mature EDphysicians will appreciate the reminders. I recommend this book for medical students and family medicine residents who intend to enter rural practice and for the libraries or rural teaching hospitals.'Canadian Journal of Rural Medicine, Vol. 3, no. 1, 1998