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Editors: Wyatt, Jonathan P.; Illingworth, Robin N.; Clancy, Michael J.; Munro, Philip T.; Robertson, Colin E. Title: Oxford Handbook of Accident and Emergency Medicine, 2nd Edition Copyright ©2005 Oxford University Press > Front of Book > Editors Editors Jonathan P. Wyatt Consultant in Accident and Emergency Medicine Treliske Hospital, Truro, Cornwall, UK Robin N. Illingworth Consultant in Accident and Emergency Medicine St James's University Hospital, Leeds, UK Michael J. Clancy Consultant in Accident and Emergency Medicine Southampton General Hospital, Southampton, UK Philip T. Munro Consultant in Accident and Emergency Medicine Southern General Hospital, Glasgow, UK Colin E. Robertson Professor of Accident and Emergency Medicine Royal Infirmary, Edinburgh, UK Editors: Wyatt, Jonathan P.; Illingworth, Robin N.; Clancy, Michael J.; Munro, Philip T.; Robertson, Colin E. Title: Oxford Handbook of Accident and Emergency Medicine, 2nd Edition Copyright ©2005 Oxford University Press > Front of Book > Disclaimer Disclaimer Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up to date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Editors: Wyatt, Jonathan P.; Illingworth, Robin N.; Clancy, Michael J.; Munro, Philip T.; Robertson, Colin E. Title: Oxford Handbook of Accident and Emergency Medicine, 2nd Edition Copyright ©2005 Oxford University Press > Front of Book > Acknowledgements Acknowledgements A number of people provided comments, help and moral support. Special thanks are due to Dr Paul Leonard. We also wish to thank: Mr David Alao, Dr Matt Baker, Dr Joan Barber, Dr Ian Beggs, Mr Dewald Behrens, Dr Ash Bhatia, Dr Angela Bonnar, Dr Ray Brettle, Dr Rachel Broadley, Dr Chris Brown, Mrs Debra Clayton, Dr James Falconer, Mrs Jennifer Flemen, Dr Debbie Galbraith, Dr Catherine Guly, Mr Andrew Harrower, Mrs Eileen Hutchison, Dr Karen Illingworth, Mr Ian Kelly, Mr Malcolm Lewis, Dr Christopher Ludlam, Mr AF Mabrook, Dr Simon Mardel, Mr Andrew Marsden, Ms Carolyn Meikle, Dr Robin Mitchell, Dr Louisa Pieterse, Miss Katharine Robinson, Ms Jeannie Ross, Ms Karen Sim, Mr Tom Scott, Dr Simon Scott-Hayward, Dr Timothy Squires, Dr Rob Taylor, Dr Mike Wells, Mr Ken Woodburn and Mrs Polly Wyatt. Editors: Wyatt, Jonathan P.; Illingworth, Robin N.; Clancy, Michael J.; Munro, Philip T.; Robertson, Colin E. Title: Oxford Handbook of Accident and Emergency Medicine, 2nd Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 1 - General approach Chapter 1 General approach P.2 Note keeping General aspects It is impossible to over-emphasize the crucial nature of note- keeping in A&E. An average junior doctor or nurse will be involved directly in the treatment of up to 3000 new patients during a 6 month period. With the passage of time, it is impossible to remember all aspects relating to these cases, but there may be a requirement to give evidence in court, several years after the initial event. The only reference will be the notes made much earlier. Medicolegally, the A&E record is the prime source of evidence in medical negligence cases (p30 ). The defence organizations have in the past had to settle cases in which the notes were deficient and because, with the passage of time, the individual could not be clear about the details of a specific patient. A court may consider the standard of a doctor/nurse's notes to reflect his or her general standard of care. Sloppy, illegible or incomplete notes reflect badly on the individual. In contrast, if notes are neat, legible and detailed, those reviewing the case will naturally expect the doctor's general standards of care, in terms of history taking, examination and level of knowledge, to be competent. The Data Protection and Access to Medical Records Acts give patients right of access to their medical notes. If, whenever writing notes, you remember that the patient may in the future read exactly what you have written, then ill-advised, judgemental or rude comments are likely to be avoided. Follow the basic general rules listed below: Layout Follow a standard outline: Presenting complaint Indicate from whom the history has been obtained (eg the patient themselves, a relative, or ambulance personnel). Avoid attributing events to certain individuals (eg patient was struck by ‘Joe Bloggs’). Previous relevant history Especially note recent A&E attendances. Include family and social history. For example, an elderly woman with a Colles’ fracture of her dominant hand may be able to manage at home with routine follow-up provided she is normally in good health and has good family or other support. If, however, she lives alone in precarious social conditions without such support, then admission on ‘social grounds’ may be required. Current medications Remember to ask about non-prescribed drugs (including recreational, herbal and homeopathic). Some women may not volunteer the OCP as a ‘medication’ unless specifically asked. Enquire about allergies to medications, and document the nature of this reaction. Examination findings As well as +ve features, document relevant -ve findings (eg the absence of neck stiffness in a patient with headache and pyrexia). Always document the side of the patient which has been injured. For upper limb injuries note whether the patient is right or left-handed. Document if a patient is abusive or aggressive, but avoid non-medical, judgemental terms, (eg ‘drunk’). Use ‘left’ and ‘right’, not ‘L’ and ‘R’. Investigation findings Record clearly. Working diagnosis For patients who are being admitted, this may be adifferential diagnostic list. P.3 Treatment given Document drug(s), dose, time and route of administration (see current BNF for guidance). Include medications given as part of treatment in A&E, as well as therapy to be continued (eg course of antibiotics). Note the number and type of sutures/staples used for wound closure (eg ‘5 × 6/0 nylon sutures’). Document if the patient and/or relative is given pre-printed instructions (eg ‘POP care’). Indicate when/if the patient requires to be reviewed by GP (eg ‘see GP in 5 days for wound check and suture removal’), or other arrangement (eg ‘return if symptoms worsen’). Basic rules Always write legibly in ball point pen, preferably in black ink, which photocopies better than pale blue. Always date and time the notes. Sign your notes and print your name and status below. Make your notes concise and to the point. Use simple line drawings or pre-printed sheets for wound/injury descriptions. Avoid idiosyncratic abbreviations. Never make rude or judgemental comments. Always document the name, grade and specialty of any doctor from whom you have received advice. When referring or handing a patient over, always document the time of referral/handover, together with the name, grade and specialty of the receiving doctor. Keep the GP informed with a written letter (p8 ), even if the patient is admitted. Most A&E departments have systems (usually computerized) which generate letters to GPs. P.4 Radiological requests ‘I am glad to say that in this country there is no need to carry out unnecessary tests as a form of insurance. It is not in this country desirable, or indeed necessary, that over protective and over examination work should be done, merely and purely and simply as I say to protect oneself against possible litigation’ —Judge Fallon, quoted by Oscar Craig, Chairman Cases Committee, Medical Protection Society. Requesting investigations The booklet published by the Royal College of Radiologists entitled ‘Making the best use of a Department of Clinical Radiology: Guidelines for doctors’ (5th edition, London, 2003) contains a large amount of very useful information and is strongly recommended. General aspects An X-ray is not a substitute for careful and thorough clinicalexamination. It is generally unnecessary to request X-rays to confirm the clinical diagnosis of uncomplicated fractures of: the nose, coccyx, an isolated rib, toes (other than the big toe). If in doubt as to the need to obtain X-rays, or the specific investigation required, consider relevant guidelines (eg Ottawa rules for ankle injuries, p463 ) and/or discuss the situation with a senior member of A&E staff or a radiologist. The information on the X-ray request card must include mechanism of injury, clinical findings (including the side involved: right or left—spelt out in full, not abbreviated) and the clinical diagnosis. This is of particular value to the radiologist, who will subsequently report the films without the advantage of also being able to examine the patient. Do not worry about which exact X-ray views are required. Leave this to the radiographer who will know what is required, based upon the information provided on the request card (eg AP + simplified apical oblique views for a patient with suspected anterior shoulder dislocation). Always consider the possibility of pregnancy in women of childbearing age before requesting an X-ray of the abdomen, pelvis, lumbar spine, hips or thighs. If the clinical indication for X-ray is overriding, tell the radiographer who will attempt to shield the fetus/gonads. If the risks/benefits of X-rays in pregnant or possibly pregnant women are not obvious, consult a senior A&E doctor or a radiologist. X-ray reporting system Many hospitals have established systems so that all X-rays taken in A&E are reported by a radiologist or senior radiographer within 24hrs. This enables appropriate action to be taken when radiological abnormalities are not initially identified by the A&E doctor or nurse.

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