| The Emergency Department Record |
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Chu Jeong-Wha |
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Department of Neurosurgery, Korea University Medical School |
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| Abstract |
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Emergency department (ED) record keeping as well as other hospital record is stringently required nowaday. Even without regulatory requirements, every physicians and nurses should be aware of various medicolegal factors that necessitate meticulous record keeping. The goal of record keeping in the ED should be to make the record as perfect as possible. All efforts should be made to accurately record all partinent informations.
Subchapters dealed in the order with medical record of emergency medical technicians, the responsibility for ED record, the composition or formate of ED record, the patient identification at ED, the consent of patient to examination and treatment, the history portion of ED record, an initial check and record of patient's vital signs, the final disposition at ED, the record recall, the inpatient record recall, the outpatient studies and physician contact, ED record change, the confidentiality of the physician-patient relationship, the state reporting requirements and the patient' right to medical records. |
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