RECORDS AND LEGAL CONSIDERATIONS

17

developed, reevaluated, and rehearsed frequently to en

hance the possibility of saving the maximum number of in
jured patients. ATLS providers should understand their role
in disaster management within their health-care institu
tions and remember the principles of l\TLS relevant (0 pa
tien t care.

Records and legal

Considerations
Specific legal considerations, including records, consent for
treatment, and forensic evidence, are relevant to ATLS
providers.

RECORDS

Definitive

Care

13 Which patients

do I transfe to a higher
level of care? When rshould the transfer
occur?

triage criteria will help determine the level,

pace, and intensity of initial treatment of the multiply in
jured patient. JI See ACS COT, Resources Jor Optima!
oJth Injured Patient,
Care 2006. These criteria take into account
ethe patient's physiologic status, obvious anatomic injury,
mechanisms of injury, concurrent diseases, and other fac
tors that can alter the patient's prognosis. ED and surgical
personnel should use these criteria to determine whether
the patien t requ ires transfer to a trauma cen tel' or closest
appropriate hospi taJ capable of providing more specialized
care. The closest appropriate locaJ facility should be cho
sen based on its overall capabilities to care [or the injured
patient. JI Sec Chapter 13: Transfer to Definitive Care and
Figure 1-1.
Interhospital

Disaster
Disasters frequently overwhelm local and regional re
sources. Plans for management of such conditions must be

Meticulous record keeping, including documenting the

time for all events, is very important. Of len more than one
doctor cares for an individual patient, Precise records are
essential to evaluate the patient's needs a.nd clinical status.
Accurate record keeping during resuscitation ca.n be facili
tated by a member of the nursing staff whose primary re
sponsibility is to record and collate alJ patient care
in formation.
Med icolegal problems arise frequcn tly, and precise
records are helpful for all individuals concerned. Chrono
logie reporting with flowsheets helps both the attending
doc lor and the consulting doctor to assess changes in the
patienr's condition quickly. JI See Appendix D: Sample
Trauma Flow Sheet, Chapter 13: Transfer to Definitive
Care, and Pigure 13.1: Sample Transfer Form.

CONSENT FOR TREATMENT

Consent is sought before treatment, if possible. in
life threatening emergencies, it is often not possible to
obtain such consent. In these cases, treatment should be
provided first, with formal consent obtained later.

FORENSIC EVIDENCE
If criminal activity is suspected in conjunction with a pa
tient's inj ury, the personnel caring for the patien t must pre
serve the evidence. AlL items, such as clothing and bullets,
must be saved for law enforcement personnel. Laboratory
determinations of blood alcohol concentrations and other
drugs DlaY be particularly pertinent and have substantial
legal implications. JI See Appendix B: Biomechanics of In.
Jury.