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History Taking, Examination, and Record Keeping in Emergency Medicine

Henry R. Guly

出版	OUP Oxford, 1996
主題	Law / Medical Law & LegislationMedical / GeneralMedical / Critical CareMedical / DiagnosisMedical / Emergency MedicineMedical / Forensic MedicineMedical / Medical History & Records
ISBN	019262461X9780192624611
URL	http://books.google.com.hk/books?id=rrJrAAAAMAAJ&hl=&source=gbs_api

註釋

Good record keeping is essential in any area of medicine - as is often stressed by the defence organizations - in order to avoid medico-legal problems as well as to ensure effective patient care. Full and accurate medical and nursing records are particularly important, and often particularly badly kept, in Accident and Emergency Departments, where the number of acutely ill patients is significant and where staff are under constant pressure. History taking, examination, and record keeping in emergency medicine will be a welcome aid to both inexperienced and more senior doctors and nurses. For the first time, this book explains what must be recorded and why - with examples of appropriate notes. The author deals not only with general principles, but also with the essential information which must be noted when confronted with various mechanisms of injury and different anatomical sites. Proformas are provided for collecting information on specific injuries. History taking, examination, and record keeping in emergency medicine goes far beyond the general examination textbooks and information pamphlets currently available. This comprehensive and specific handbook will equip all members of the A&E team and other clinicians to keep better records and to avoid criticism, complaints, and even legal action.