Oxford Handbook of Accident and Emergency Medicine

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).

 

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