Emergency Medicine

DESIRABLE HABITS OF THE GOOD EMERGENCY DEPARTMENT DOCTOR

Administrative and Legal Issues 447

(i) Statements may subsequently be required by the police or a

solicitor, and could be requested months or even years later, so

you cannot rely on your memory.

(ii) A photograph is an invaluable record and may save a detailed

description. Access to a suitable digital camera is ideal, provided

that written and signed consent to take the photo is obtained

from the patient.

(iii) Keep the consent and the photo in the medical record.

6 Record your diagnosis and differential diagnosis.

7 Record any investigations performed, and put down the results, including
your own interpretation of the electrocardiogram (ECG) or X- ray.

8 Record whether you discussed the case with a senior ED doctor, their name
and grade, the time, and exactly what they advised.

9 Detail your proposed treatment plan, printing drug names and quantities.

10 Document any verbal or written instructions or advice given to the patient.

11 Record the disposition of the patient.
(i) Record on the notes to whom clinical responsibility has been
transferred, if you hand the patient over to another ED doctor at
the end of your shift.
(ii) Record the name and seniority of the doctor concerned, if you
refer to an inpatient team, and the time the patient was referred.
(iii) Record the clinic name and the consultant if possible, when a
patient is referred to outpatients.
(iv) Write the ward and the consultant under whom the patient was
admitted, when a patient is admitted.
(v) Attach a copy to the ED record of any discharge letter to the GP,
when the patient is referred back to their own doctor
(a) computerization of the medical record now enables a printed
letter to be generated for every patient discharged home.

12 Sign your name clearly at the end of the record, and print your name and
initials underneath for future identification.

Communicating with the general practitioner

Communicate whenever possible with the GP.

1 Ring the GP to clarify current management, including medications and
allergies when the patient is unsure, or for a recent past history in complex or
atypical presentations.

Tip: most of the above points may appear obvious, but they are

essential to the quality and continuity of the medical care of the patient,

and underpin good risk management practice.

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