Điều gì có thể được hoàn toàn đầy đủ hồ sơ y tế cho một bong gân mắt cá chân đơn giản không có ý nghĩa pháp lý, có thể không đầy đủ cho các chấn thương xảy ra tại một trung tâm mua sắm, hoặc trong một cuộc tấn công. Hãy ghi nhớ rằng các tòa án chấp nhận đúng nguyên văn | The Gist of Emergency Medicine 20 their past history take full precautions nurse present during all encountering . Do not use the fear of allegations as an excuse for omitting indicated examinations. 21 Remember the medical record can be your best friend. Records don t necessarily have to be extensive but they need to be complete with the times of your assessments and reassessments in addition write down on the patient s chart the results of your investigations . EKG X-rays CBC ethanol level also with the times prn . What may be a perfectly adequate medical record for a simple ankle sprain with no legal connotations may be inadequate for the same injury occurring in a shopping centre or during an assault. Keep in mind that the courts generally accept verbatim and do not challenge your medical record that was written in your own handwriting during or immediately following the patient s visit including ethanol levels at least that has been my experience . In court have a copy of your chart with you and stick to it as much as possible otherwise the lawyer for the other side may try to trip you up and discredit your testimony . assault victim s injuries the injuries were consistent with the patient s description of how the injuries occurred . punched kicked choked or the injuries were consistent with but not specific for being assaulted . Charting as you go is particularly useful when you have several patients with various problems on the go helps compensate for a fading short term memory for example an assortment of patients with an assortment of problems such as fever alcohol drug abuse overdose asthma COPD chest abdominal pain trauma migraine . bleeding ureteral calculus. Again remember to start out each notation with the time. 22 When patients ask why did I get this avoid long convoluted explanations especially when the etiology is unclear. You may only exacerbate the patient s confusion rather than alleviate it. With minor problems . bursitis I .
