Author Description
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.
Menrva's Summary
THE THESIS
This text investigates the critical necessity of precise documentation in emergency medicine for both patient safety and medico-legal protection. Author Henry R. Guly, an experienced practitioner, provides a structured framework for clinical record-keeping. The book synthesizes clinical requirements with legal standards to ensure that practitioners maintain accurate, defensible, and comprehensive patient notes.
THE SCOPE MAP
What You Will Find
- Guidelines for general record-keeping in emergency departments
- Specific documentation requirements for various mechanisms of injury
- Anatomical checklists for clinical examinations
- Proformas for standardized data collection
- Examples of high-quality clinical notes
Scope Limits
- Does not cover advanced surgical procedures or diagnostic imaging interpretation
- Focuses primarily on the documentation process rather than clinical treatment protocols
THE AUTHORITY PERSPECTIVE
Experts identify this text as a practical resource for clinicians navigating the complexities of medical documentation. Readers frequently note the clarity of the provided examples and the utility of the included proformas for daily practice.
Page Count:
240
Publication Date:
1996-07-11
Publisher:
Oxford University Press
ISBN-10:
019262461X
ISBN-13:
9780192624611
Reference
Emergency medicine
Professional Development
Medical
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