Articles: emergency-services.
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Eight records used in six accident and emergency (A/E) departments in the Mersey Region were reviewed. We studied (1) the structure of records; (2) the printed matter on the record; (3) the designated areas for documentation by the administrative, nursing and medical staff; and (4) the advantages of the records in transferring information to other departments and general practitioners. The use of computers in the departments was investigated. ⋯ None of the accident and emergency departments used computers for either delayed or real-time recording of patients' details. A computer-structured A/E Record will produce a legible, factual patient history, examination and care plan. The information recorded will be easily transferred to relevant hospital departments and ultimately to the community practitioners.
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This paper describes the development of a comprehensive, practical audit by the medical staff at the Accident and Emergency Department at Guy's Hospital. The audit has enabled a comprehensive systematic review of clinical care and its documentation. The results shows that audit of Accident Emergency medicine is possible when channelled by proforma. Junior doctors in this specialty exercise great autonomy, and the audit highlights their need for proper training and guidance from senior medical staff in the review of major and minor cases.