Font
Large
Medium
Small
Night
Prev Index    Favorite Next

Chapter 62 Medical Records

"Mr. Tang's operation was very successful." Huo Congjun walked out of the operating room door and told the anxiously waiting patient's family members what they wanted to hear most.

The patient's family members who gathered together suddenly became happy, and several women even cried with joy.

Huo Congjun said a few more words of comfort and gave the doctor's instructions before leaving.

The patient was lying on a flat bed and was pushed back together with his family members.

Huo Congjun also breathed a sigh of relief, smiled and nodded at Ling Ran who came out from behind.

Ling Ran also nodded and walked in the opposite direction.

Today's operating rooms are all multi-functional. The interior of the operating room is the same, and there are multiple ways to leave. The patients guard the one closest to the ward, and the doctors don't leave even if they can.

Lu Wenbin followed Ling Ran nervously, feeling as if he was going to an Internet cafe with someone for the first time.

That little happiness, that little entanglement, that little regret, that little expectation made him feel like a little teddy, wishing he had something right now that he could mess with for a while.

"Dr. Ling, what should we do next?" Lu Wenbin was itching to do three hundred more tangs and become a well-known figure in the country in one fell swoop.

"Teach me how to write medical records." Ling Ran's reply instantly pulled Lu Wenbin back to Earth from Kepler 76b-Albert Einstein.

"Shall I teach you how to write medical records?" Lu Wenbin repeated, and then he suddenly realized: "You just started your internship, and you haven't even started writing medical records yet?"

"Yes. I haven't written much." Ling Ran said.

"Then what did you do?"

"Debridement and suturing, hemostasis with bare hands, and then the Tang method." Ling Ran counted the numbers and then said, "The emergency department is the first department where I did my internship rotation."

Lu Wenbin looked at Ling Ran with extremely complicated emotions.

From the first half of the sentence, it sounds like Ling Ran has done everything a surgeon should do.

After listening to the second half of the sentence, I was convinced that I didn’t do anything.

"You should also write a medical record after debridement and suturing. Have you ever written a simple version?" Lu Wenbin was a little curious.

"I've written it several times." Ling Ran said.

"Only a few times? What about the rest of the medical records? Did Dr. Zhou write it?" Lu Wenbin felt that because of Dr. Zhou's laziness, it was wrong. Because of Dr. Zhou's character, it was impossible for him to do such a thing.

Ling Ran also glanced at Lu Wenbin strangely and said, "There are other interns who helped write it."

During the few days he was in the treatment room, there happened to be an explosion in the factory, and everyone was busy. He could suture, so he naturally got to work, and the other interns who were no longer needed were responsible for taking care of things, writing medical records, etc.

Lu Wenbin only felt that the world was a little weird.

What kind of life was he living during his internship? For a whole year, sewing skin felt like Chinese New Year.

Of course, the so-called talented interns during the same period did get more opportunities. Those who could learn debridement and suturing easily, made no mistakes when entering the operating room, retracted hooks without getting scolded, cooperated well with suction, and closed the abdomen.

Students who did not bleed more or less had the opportunity to have their appendix removed, hemorrhoids removed, circumcision, etc.

However, Lu Wenbin really didn't expect that the gap in talent could be so big.

Lu Wenbin chuckled twice and said, "I didn't expect that interns would always help me."

Nurse Wang, who was reluctant to leave Dr. Ling immediately, looked at the resident doctor Lu Wenbin who was talking in surprise...

Lu Wenbin suddenly came to his senses. Yes, Ling Ran, an intern, already had a resident doctor to help him. What's even more tragic is that the resident doctor who helped Ling Ran was himself.

Lu Wenbin silently brought Ling Ran to the office, silently turned on his computer, silently logged into his electronic workstation, pointed at a long row of words, and said: "Now you need to fill in the pre-operative summary, hospitalization medical record, pre-operative summary, etc."

Discussion records, surgical records, long-term medical orders and temporary medical orders..."

"What we did today can be filled in on the surgical record sheet. You can click here." Lu Wenbin gave up his seat to Ling Ran.

The header of the surgical record sheet is the patient's name, gender, department, bed number, date of surgery, etc., followed by a few short sentences including preoperative diagnosis, intraoperative diagnosis, surgical content, operating personnel, anesthesia method,

Anesthesia staff, etc…

Although the record sheet is electronic, all the contents can be printed directly and become a paper medical record, and the content composition is as cumbersome as the previous paper medical records.

"The template looks like this. It's actually quite simple..." Lu Wenbin introduced each item one by one.

Letting interns or trainee doctors write medical records is actually the most common way for residents to be lazy.

Every year, several batches of interns and training doctors come to the department for rotation, so the residents have to teach people how to write medical records several times every year.

Lu Wenbin is somewhat proficient at this, not to mention that the medical record system does not have any complicated modules, it is just simple and cumbersome.

Ling Ran listened carefully, then followed the instructions in the case, and started to fight.

"Preoperative diagnosis, the first is thumb tendon rupture, the second is tendon contusion..." Ling Ran's diagnosis of Tang suture and the course of the disease are all master-level. All he needs is familiarity with the writing of official documents about the case.

Lu Wenbin looked at it and laughed to himself twice, and said: "Actually, you can copy and paste..."

Ling Ran then copied and pasted two paragraphs. When filling in the medical record, he felt uncomfortable all over. It wasn't until he deleted it that he felt relieved.

Snap.

Bang bang bang.

Snap, snap, snap.

The pleasant sound of the keyboard resounded once again with a pleasant sound.

Lu Wenbin felt uncomfortable all over.

Is the copy-paste method good? Of course it is. After pasting, you only need to modify it once, which can be said to be fast and good. Therefore, even though there are old stubborns who emphasize manual injection, young doctors never listen.

Lu Wenbin has always believed that copying, pasting and then revising is the most normal way of writing medical records. It is a new method under new technologies and no one will ask for trouble.

He didn't expect that Ling Ran would choose the hand-playing mode without hesitation.

And it hits very fast.

It's like there's not much need to think about it.

However, a case with thousands of words can be tiring to type by hand.

Lu Wenbin wanted to laugh at Ling Ran's naivety, but he couldn't.

If someone is talented and skilled and is valued by the leadership, but he is still making cases, what right do you have to laugh at him?

Lu Wenbin looked at Ling Ran's dancing fingers with admiration and emotion, and gained a new understanding of his medical path.

At the same time, Ling Ran also sighed in his heart: Copying, pasting and then revising the article is simply heresy, just like wrapping meat in a dumpling. Fortunately, it is not necessary.

Ling Ran finished writing one paragraph and then another, not too slowly.

Medical records do not pay attention to writing. As long as you write things clearly and clearly, you can list them, you can have no connections, as long as you can understand them. In fact, if the requirements of the superior doctor are not strict, you can just write them casually.

Just passed the test.

The single skill book Ling Ran obtained fully acquired the Tang Method skills. The medical records written in the Tang Method were still master-level, and the surgery was performed by himself. He only needed to check some pre-examination data, which made it even more obvious.

easy.

After writing, check, and then fill in a new form.
Chapter completed!
Prev Index    Favorite Next