History Taking, Examination, and Record Keeping in Emergency Medicine by H. R. Guly (Consultant in Emergency Medicine, Consultant in Emergency Medicine, Derriford Hosital, Plymouth)
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.