DIAGNOSIS - Medicine for Mountaineering and Other Wilderness Activities - page 7

If the person is evacuated, written records are essential for the physician who provides
care, particularly when attendants are unable to accompany the individual. If evacuation
takes place several days after onset of an illness or injury and more than one person has
been involved in the person's care, a written record is the physician's only source of accur-
ate information about the individual's original condition, how that has changed, and what
treatment has been given—particularly medications that have been administered.
Medical records play such a vital role in medical care that their compilation is begun
immediately when someone enters a hospital emergency room or physician's office. Such
records are subpoenaed at the beginning of any medically related litigation, and omissions
are often damaging to the physician's defense, which might be a significant consideration
for nonphysicians in an increasingly litigious society.
The outlines provided in this chapter for the medical history and physical examination
are entirely appropriate for the medical record. Obviously, all abnormalities should be re-
corded, but the absence of abnormalities is frequently of equal importance, particularly
for nontraumatic disorders. Without a specific statement that a sign or symptom was not
present, a physician subsequently caring for the individual may be unable to determine
whether that indicator was really absent or simply was not noticed.
For traumatic injuries, an account of the accident should be recorded at the earliest
opportunity. All injuries should be carefully described. The absence of injuries, or signs
such as swelling or discoloration that are suggestive of injury over major areas of the
body—chest, abdomen, head, arms, or legs—should also be noted. The vital signs should
berecordedeverythirtytosixtyminutesforatleastfourhours,butforlongerifthesesigns
are not stable. After stabilization, vital signs need to be recorded only about every four
hours until the person is well on the way to recovery. Any preexisting medical conditions
should be described. The dosage, route, and time of administration of all medications must
be accurately logged. Notes about any other treatment or changes in the person's condition
must include the time.
Thewrittenrecordmustbeaccessible—notburiedawayinapack.Notationsofchanges
in the individual's condition or the administration of medications must be made immedi-
ately and not recorded from memory later.
____________
REFERENCES
1 . Adams, F. D. Cabot and Adams Physical Diagnosis, 14th ed. Baltimore: The Willi-
ams & Wilkins Co., 1958. Quoted by permission of the author and publishers.
2 . Ibid.
3 . Kennedy, R. H. in Committee on Trauma, American College of Surgeons: Early
Care of Acute Soft Tissue Injuries . Chicago, 1957. (Quoted by permission of the publish-
ers.)