History Taking Record Keeping
H. R. Guly
Also available as:
$168.95 AUD
- ISBN:
- 9780192624611
- Published:
- 28 Mar 1996
- Availability:
- Print on demand
Good medical and nursing records are essential in A&E for adequate clinical care as well as for medico-legal reasons. This book describes, with many examples, the information that A&E records should contain. Some pro-formas for collecting information on specific injuries are given and there are many examples of appropriate notes.
This book will provide expert guidance for doctors and nurses in A&E departments
Inroduction
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
H. R. Guly , Consultant in Emergency Medicine, Derriford Hosital, Plymouth
`This little book contains wise tips for physicians and nurses who work in emergency departments. This book is seeded with tips about understanding the patient's agenda while attempting to make an accurate diagnosis. New students will benefit from early exposure to this wisdom, and mature ED physicians will appreciate the reminders. I recommend this book for medical students and family medicine residents who intend to enter rural practice and for the libraries or rural teaching hospitals.' Canadian Journal of Rural Medicine, Vol. 3, no. 1, 1998