Oxford Handbook of Accident and Emergency Medicine, 2nd Edition

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

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. 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.

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