History taking, examination, and record keeping in emergency medicine
著者
書誌事項
History taking, examination, and record keeping in emergency medicine
（Oxford handbooks in emergency medicine, 12）
Oxford University Press, 1996
- : hbk
- : pbk
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注記
Includes bibliographical references
Includes index
内容説明・目次
- 巻冊次
-
: pbk ISBN 9780192624611
内容説明
Good record keeping is essential in medicine, a point often stressed by the defence organizations. A & E records are frequently very bad - which may cause medicological problems as well as impairing effective patient care. The reason is inexperience. This book explains what it is important to record (and why) and gives examples.
Good records are essential in A & E. This book explains the reasons for keeping good records and describes how A & E records should be kept, both in general terms nad emphasizing the essential information to be recorded with different mechanisms of injury and in different anatomical sites. Some performas for collecting information on examination, especially orthopaedic and neurological examination, but none which specifically covers record-keeping or even discusses it other than to
stress its importance. There are pamphlets for medical students often provided by individual medical schools, but these just cover general medicine and surgery.
目次
- Introduction
- Reasons for good notekeeping
- Basiuc 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
- wounds
- 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 B Sc, RGN
- 巻冊次
-
: hbk ISBN 9780192624628
内容説明
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. This book is essential reading for the new A&E doctor and A&E nurse practitioner. This book is intended for sHOs working in accident and emergency medicine. A&E nurse practitioners. All junior doctors required to examine patients and keep clinical notes.
目次
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
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