History Taking, Examination and Record Keeping in Emergency Medicine

Good medical and nursing records are essential in accident-and-emergency for adequate clinical care as well as for medico-legal reasons. This text describes, with examples, the information that A&E records should contain. It should be useful for the new A&E doctor and nurse practitioner.

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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. This book is essential reading for the new A&E doctor and A&E nurse practitioner. This book is intended for sHOs working in accident and emergency medicine. A&E nurse practitioners. All junior doctors required to examine patients and keep clinical notes.