History Taking, Examination, and Record Keeping in Emergency Medicine / Edition 1

by Henry R. Guly

Overview

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.

Product Details

ISBN-13:	9780192624611
Publisher:	Oxford University Press
Publication date:	07/11/1996
Series:	Oxford Handbooks in Emergency Medicine , #12
Edition description:	New Edition
Pages:	240
Product dimensions:	5.40(w) x 8.50(h) x 0.90(d)

Table of Contents

Introduction
Reasons for good notekeeping
Basic pattern of notes
History
Examination
X-rays and other investigations
Diagnosis
Practical procedures
Drugs
Advice
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
Burns
Road Traffic Accidents
Major Trauma
Deliberate self harm
Nursing notes by A.M. Jenkin BSc, RGN

Editorial Reviews

Reviewer: Nancy S. Clark, MD (University of Chicago Pritzker School of Medicine)
Description: This handbook from England focuses on the history and physical examination of injuries and record keeping in the emergency department. This book does not deal with nontraumatic illnesses.
Purpose: The author tries to provide residents a framework for complete and pertinent charting of specific injuries. This is a topic not usually addressed directly by most textbooks.
Audience: Medical students would find this book helpful during a clinical rotation in emergency medicine. A section on nursing documentation may be of interest to nurses.
Features: Each short chapter focuses on a single body area. There are several black-and-white illustrations of preprinted charts. Sample documents illustrate the pertinent aspects of the history and physical exam. These sample records become repetitious, and the use of British words and abbreviations can be confusing. There are few references. Overall, the book is clear and easy to use.
Assessment: This book provides good guidelines for documentation in the emergency department. This is a very basic book that could be helpful to medical students and junior residents, but it will not find a place in the library of the practicing emergency physician.

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