Record Keeping

paperwork1.gif

Exhaustive patient clerking is NOT necessary in the Emergency Department. Documentation should be concise, relevant with only relevant negative symptoms and signs recorded.

Medical records are not infrequently required by solicitors and you may be asked to write police or other statements on them a considerable time after you have seen and even forgotten the patient.  This should be borne in mind when writing notes.  All Emergency Department notes must contain the following points and headings and every entry must be signed.

Top of page

Name of doctor (capitals)

Grade: SHO/FY2/VTS/MG/SpR/ST2 etc

Time patient seen.

Date.

Text

History-including mechanism of injury and timing.

Only relevant previous medical/drug/family history & allergies

Examination-use the diagrams and document the types and dimensions, document relevant negatives

Investigations. Always comment on results if you have seen them (ECG, CXR etc). You are obliged by the GMC to review any results of investigations you initiate (except when referring a patient to a specialty, when you DO NOT NEED TO, unless it will alter who you refer to eg Amylase in pancreatitis)

Diagnosis or differentials

Treatment -including advice given.

Disposal -including referral (name, status and time).

Follow-up.

Trauma

Please write the notes in the order you assess and treat the patient:

Primary Survey: 

Airway with collar/blocks; 

B: Resp rate, AE left and Right and Sats with O2 15L, 

C: Pulse, BP, CRT and lines

D: GCS, pupils and neuro exam

E: etc etc. 

Document any intervention as you do them eg needle thoracocentesis with 'B' before you move onto 'C'

Followed by A-M-P-L-E history (Allergies, Medications, Previous illness, Last ate, Environment of incident)

Log roll and findings in head, neck, back, back of chest and PR

Secondary Survey

Details of the Top to Toe exam

Trauma series of x-rays (CXR, Pelvis etc)

Investigations with results if avaible

Referral. to whom and when.

Note team members present if Trauma Call (eg Anaesthetic SpR, Surgical SHO etc)

Note any discussion with relatives

Resuscitation

Pre-hospital times and findings eg asystole

Treatment on scene and on route (cannulation, intubation, drugs, [eg adrenaline x2], number of shocks)

Assessment on arrival of, P, RR, BP, GCS and rhythm on monitor

Management, such as: number of cycles, adrenaline and atropine etc 'as per ALS protocol'

Time of confirmation of death

Team members present

Note any discussion with relatives