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St James' ED General Management
1.9 Note Keeping and Documentation
Read this section very carefully. It is VERY important and will help us to defend you against any complaints that may arise.
Front Page The front page of the Accident & Emergency card will give you a lot of useful information, such as the patient’s GP’s address and telephone number and whether the patient has attended before etc. You MUST MAKE SURE when you see the patient to fill in your name (in block letters legibly), your personal code, the time (on a 24 hr basis) you saw the patient. Make sure to record the time that you DISCHARGE the patient from A&E as well.
We routinely send information to all local GP practices on a weekly basis, giving summary data for each attendance identified with that practice. This provides a communication safety net, but the data will be of poor quality unless the card is completely coded.
PLEASE PLEASE PLEASE:
- Make sure to record the time that you see the patient, the time that you discuss the patient with a specialty doctor and the time that you discharge the patient from the A&E dept. All of these are critical and will help us to defend you if there is a complaint from a patient or there are medico-legal consequences. Please also enter these times on the computer tracking screen
- Your notes are a legal record. Make your history and examination concise, but clear and above all legible and always signed. A high standard of documentation should be maintained by including the date and time you saw the patient and you’re working diagnosis or diagnoses. Make use of illustrations where necessary.
- X-rays are requested on a green time. It is helpful to the x-ray department to record the patients 4 hour target time. Once you have interpreted the films record your diagnosis in the box on the right side of the card. This will allow a Radioligist who reports the film to make a judgement on whether the x-ray report needs to be brought to our attention and the patient brought back for review.
- The documentation should include the management plan, including the treatment prescribed, investigations requested and the time of sending them. The results of investigations, the disposal of the patient (including the time of discharge/referral) and the advice given to the patient must be recorded. Take particular care with RTAs and assault cases to note all the relevant details of the mechanism of injury described to you, and the injuries noted.
- You must also record whom you have handed over the patient to so that unnecessary confusion and delays can be avoided.
Special Forms – Special forms may be needed to be filled in for trauma patients, chest pain, and random research projects. Under these circumstances you do not have to duplicate information by writing in the Accident & Emergency card. A brief summary on the A&E card is sufficient as long as a copy of the form remains with the card.
Other Special Forms – For ethical and medico legal purposes some additional forms may have to be filled in by yourself and the patient. Examples of these include refusal of treatment/or admission, consent form for operation/procedures, consent form for trials etc. These are available in the cabinets placed in the Central Area.