Adult Medical Emergency Handbook - Scottish Intensive Care Society

i
GOOD DOCUMENTATION
• Write legibly, preferably in black ink (so it can be easily read when
photocopied).
• Write the patient’s name, date of birth, CHI number at the top of
each page (each side).
• Remember that the medical case record is a legal document to
which patients and relatives have right of access.
• All entries into case records should have a date and time assigned
to them, and be completed in a way that allows the writer to be
identified. Print your name.
• Keep notes in chronological order: if writing retrospectively say so.
• Keep clear progress notes both for inpatients and outpatients.
• Make clear your reasoning for clinical decisions.
• Any typed notes should be checked, corrected and signed.
• Cross out errors and write a corrected entry, dated and signed.
• Record details of discussions with patients or relatives.
• Record discussion of the patient’s condition or about risk/benefit
of therapy.
• Any untoward or unexpected events and action taken in response
to them should be adequately documented.
• At all times remember that the written record documents your
thoughts for others to read.
GOOD PRESCRIBING
When a patient is admitted as an emergency consider which
medicines may worsen the acute problem and omit until it is
appropriate to restart.
Good Practice in Writing Prescriptions on the Prescription and
Administration Record (Drug Kardex)
A clearly written prescription:
• saves everybody’s time.
• reduces the risk of medication errors.
• helps ensure the right patient receives the right medicine in the
right form and right dose by the right route at the right time.
• provides a clear record of the patient’s drug therapy.
22 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11