History Taking, Examination, and Record Keeping in Emergency Medicine (Oxford Handbooks in Emergency Medicine)

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.