I really don't want to be a doctor
Chapter 126 Principles of Writing Medical Records
Chapter 126 Principles of Writing Medical Records
Yu Wenxing's name,
Over the past month or so, thunderstorms have been heard countless times.
Every time Gu Jianjun had surgery, he would repeat this name.
Lei Shower has also portrayed Yu Wenxing's appearance in his mind many times,
but,
He never imagined,
The other party turned out to be an intern.
An intern who pioneered the two-hole method and then the one-hole method? ? ? !
special,
Why does this character look so much like the protagonist? ?
"You mean?" Lei Showyu struggled to sort out his nearly muddled mind,
But still he tidied up for a long time,
He didn't know what to say.
"Mr. Lei, let's see the patient first, and I will introduce Dr. Yu to you later."
Li Xiaojun also saw that Lei Showyu seemed to be going crazy, so he quickly changed the subject.
"That's OK, that's OK."
The thunderstorm also hurriedly borrowed the donkey to go downhill.
"Mr. Lei, I know the reason why you and Mr. Gu are here. I will mainly introduce you to the patients of the two-hole technique."
Li Xiaojun straightened his back slightly, "Look, this is the patient we did yesterday, the two-hole method."
"Let me see"
As soon as he talked about professional matters, Lei Xiuyu suddenly sobered up, "Well, let me take a look."
After receiving the medical record card handed over by Li Xiaojun, Lei Zhenyu read it,
病人78岁,是昨天下午1点10分开始麻醉的,2点00分离开手术间的。
"Five or six minutes?"
Lei Shower nodded, "Five to 10 minutes is not bad, including the time for anesthesia recovery."
Five to 10 minutes is not fast for laparoscopic resection of an appendix.
but,
It is also considered qualified.
After reading the medical records, Thunderstorm began to check on the patient, "Have you exhausted?"
The patient froze for a moment, with a puzzled expression on his face.
"I said, are you exhausted?"
Seeing that the other party didn't seem to hear clearly, the thunderstorm increased the volume.
The patient remained bewildered.
"cough,"
Li Xiaojun coughed lightly, "Mr. Lei, we are a county-level hospital with a low level of education, and this patient is an old farmer who has never read any books before. You asked him if he was exhausted? He didn't understand. You should ask .”
As he spoke, Li Xiaojun raised his voice and shouted at the patient, "Did you fart?"
"Let it go, let it go, I let it go yesterday afternoon, and I feel relaxed."
The patient understood at once, and the doubt on his face was replaced by joy, and he answered quickly.
"Oh"
The thunderstorm suddenly realized that it was speechless,
That should be the original question.
After looking at the incision and touching the patient's abdominal signs, Lei Showyu had a general understanding of the patient's condition and praised, "It seems that your hospital has done a good job in the two-hole method. The recovery speed of the two-hole method It is not slower than the traditional three-hole method, and this is indeed a new technology that is very suitable for development."
"Where.Where"
Li Xiaojun laughed humbly.
Thundershower obviously also inherited the characteristics of a surgeon, and the rounds were extremely fast. Li Xiaojun followed Thundershower, leaving those inexplicable explanations to Song Rentou.
"It's made by the three-hole method,"
"This is made using the two-hole method,"
"It's done by the two-hole method."
"It's made by the single hole method"
When pointing to this patient, the thunderstorm stopped suddenly.
Single hole method! !
Isn't this the purpose of my trip?
"Let me see the medical record."
Lei Xieyu said anxiously.
Li Xiaojun handed the medical record card to Lei Shower,
Thunderstorm quickly turned to the operation record, and almost fainted.
1. The patient is in the supine position. After successful anesthesia, routine disinfection, draping, and pneumoperitoneum are established, and instruments are poked below the navel.
2. During the operation, it was found that the appendix was about 7cm in length and 1.1cm in diameter, congested and edematous, with no surface pus, gangrene and perforation, and no abnormalities.
3. Open the intestine with gauze strips, find the appendix, lift the appendix, separate the mesentery, clamp the root of the appendix, and coagulate the appendix with an electric knife.
4. Take out the appendix and absorb 5ml of pus for culture;
5. After the operation, the patient returns to the ward safely.
"You, you. The operation record is so simple???"
The thunderstorm almost made me curse,
What about the one-hole method?
At least in this surgical record, Lei Shower did not see the slightest shadow of how the single-hole method was operated.
The only thing that can prove that this is a single-hole method,
There is only the first point of the operation record: poking a hole under the navel and inserting the instrument.
Is your fucking surgery done after you put in the instruments?
How did you bring up the appendix?
How to separate the mesangium?
This most critical step,
A hammer can be seen in this fucking surgery record!
This is not a three-port laparoscopic appendectomy that has been performed many times,
You can write whatever you want, everyone can imagine it,
This is the single hole method!
And it's the only single-hole method!
You write the operation record like this,
Are you sorry for this new technique?
"This"
Li Xiaojun is a bit hypocritical,
This operation record was indeed written by him,
But he wrote it casually,
When doing three-hole laparoscopy, although he didn't have a template, there are ready-made ones on the Internet, and he can just cut it out.
When doing the two-hole method, there is no template on the Internet.
But Li Xiaojun can still distinguish the operation steps, and he can also write them down.
but.
He really didn't know what kind of language Yu Wenxing should use to express those coquettish operations when he was doing the single-hole method.
But he remembered a principle,
That is:
Brief and concise!
As long as you write simple enough,
Then no one else can trouble you,
If you didn’t write it down, then at most you missed it;
You wrote it wrong,
That would be a big trouble,
This is why there is such a saying in the medical field: Do more and make more mistakes, do less and make fewer mistakes, and it is good not to do it!
Li Xiaojun has accurately grasped the principle of writing medical records,
I can't write anyway,
Then I won’t write it.
"Teacher Ray"
Seeing that the thunderstorm was suffocating, Li Xiaojun hurriedly yelled.
"Were you on the operating table?"
The thunderstorm is almost dizzy,
He didn't want to think about it, could he write the operation records without being on the operating table?
"exist."
"Then please explain the operation process in detail."
The thunderstorm clipped the medical record card,
He also knew that nothing could be seen on it, and he could only comfort himself that it was probably for the sake of keeping it secret.
"Uh"
Li Xiaojun sorted out his language, and told the process in slobber.
After all, Thundershower understood.
I also understood Li Xiaojun,
Too,
It is really difficult to express the operation record of a new operation method clearly and concisely.
After all, this technique has too many new operations.
For example, the ligation and trocar needle is pulled out of the body to form a fixation,
For example, by moving the position of the needle to achieve the purpose of pulling the appendix,
After recalling the entire operation in my mind, I immediately asked about the patient's situation and got a positive response. At least in a short period of time, it seemed that there was not much difference between the two-hole method and the three-hole method.
Thunderstorm sighed:
This doctor Yu's idea is really a genius!
(End of this chapter)
Yu Wenxing's name,
Over the past month or so, thunderstorms have been heard countless times.
Every time Gu Jianjun had surgery, he would repeat this name.
Lei Shower has also portrayed Yu Wenxing's appearance in his mind many times,
but,
He never imagined,
The other party turned out to be an intern.
An intern who pioneered the two-hole method and then the one-hole method? ? ? !
special,
Why does this character look so much like the protagonist? ?
"You mean?" Lei Showyu struggled to sort out his nearly muddled mind,
But still he tidied up for a long time,
He didn't know what to say.
"Mr. Lei, let's see the patient first, and I will introduce Dr. Yu to you later."
Li Xiaojun also saw that Lei Showyu seemed to be going crazy, so he quickly changed the subject.
"That's OK, that's OK."
The thunderstorm also hurriedly borrowed the donkey to go downhill.
"Mr. Lei, I know the reason why you and Mr. Gu are here. I will mainly introduce you to the patients of the two-hole technique."
Li Xiaojun straightened his back slightly, "Look, this is the patient we did yesterday, the two-hole method."
"Let me see"
As soon as he talked about professional matters, Lei Xiuyu suddenly sobered up, "Well, let me take a look."
After receiving the medical record card handed over by Li Xiaojun, Lei Zhenyu read it,
病人78岁,是昨天下午1点10分开始麻醉的,2点00分离开手术间的。
"Five or six minutes?"
Lei Shower nodded, "Five to 10 minutes is not bad, including the time for anesthesia recovery."
Five to 10 minutes is not fast for laparoscopic resection of an appendix.
but,
It is also considered qualified.
After reading the medical records, Thunderstorm began to check on the patient, "Have you exhausted?"
The patient froze for a moment, with a puzzled expression on his face.
"I said, are you exhausted?"
Seeing that the other party didn't seem to hear clearly, the thunderstorm increased the volume.
The patient remained bewildered.
"cough,"
Li Xiaojun coughed lightly, "Mr. Lei, we are a county-level hospital with a low level of education, and this patient is an old farmer who has never read any books before. You asked him if he was exhausted? He didn't understand. You should ask .”
As he spoke, Li Xiaojun raised his voice and shouted at the patient, "Did you fart?"
"Let it go, let it go, I let it go yesterday afternoon, and I feel relaxed."
The patient understood at once, and the doubt on his face was replaced by joy, and he answered quickly.
"Oh"
The thunderstorm suddenly realized that it was speechless,
That should be the original question.
After looking at the incision and touching the patient's abdominal signs, Lei Showyu had a general understanding of the patient's condition and praised, "It seems that your hospital has done a good job in the two-hole method. The recovery speed of the two-hole method It is not slower than the traditional three-hole method, and this is indeed a new technology that is very suitable for development."
"Where.Where"
Li Xiaojun laughed humbly.
Thundershower obviously also inherited the characteristics of a surgeon, and the rounds were extremely fast. Li Xiaojun followed Thundershower, leaving those inexplicable explanations to Song Rentou.
"It's made by the three-hole method,"
"This is made using the two-hole method,"
"It's done by the two-hole method."
"It's made by the single hole method"
When pointing to this patient, the thunderstorm stopped suddenly.
Single hole method! !
Isn't this the purpose of my trip?
"Let me see the medical record."
Lei Xieyu said anxiously.
Li Xiaojun handed the medical record card to Lei Shower,
Thunderstorm quickly turned to the operation record, and almost fainted.
1. The patient is in the supine position. After successful anesthesia, routine disinfection, draping, and pneumoperitoneum are established, and instruments are poked below the navel.
2. During the operation, it was found that the appendix was about 7cm in length and 1.1cm in diameter, congested and edematous, with no surface pus, gangrene and perforation, and no abnormalities.
3. Open the intestine with gauze strips, find the appendix, lift the appendix, separate the mesentery, clamp the root of the appendix, and coagulate the appendix with an electric knife.
4. Take out the appendix and absorb 5ml of pus for culture;
5. After the operation, the patient returns to the ward safely.
"You, you. The operation record is so simple???"
The thunderstorm almost made me curse,
What about the one-hole method?
At least in this surgical record, Lei Shower did not see the slightest shadow of how the single-hole method was operated.
The only thing that can prove that this is a single-hole method,
There is only the first point of the operation record: poking a hole under the navel and inserting the instrument.
Is your fucking surgery done after you put in the instruments?
How did you bring up the appendix?
How to separate the mesangium?
This most critical step,
A hammer can be seen in this fucking surgery record!
This is not a three-port laparoscopic appendectomy that has been performed many times,
You can write whatever you want, everyone can imagine it,
This is the single hole method!
And it's the only single-hole method!
You write the operation record like this,
Are you sorry for this new technique?
"This"
Li Xiaojun is a bit hypocritical,
This operation record was indeed written by him,
But he wrote it casually,
When doing three-hole laparoscopy, although he didn't have a template, there are ready-made ones on the Internet, and he can just cut it out.
When doing the two-hole method, there is no template on the Internet.
But Li Xiaojun can still distinguish the operation steps, and he can also write them down.
but.
He really didn't know what kind of language Yu Wenxing should use to express those coquettish operations when he was doing the single-hole method.
But he remembered a principle,
That is:
Brief and concise!
As long as you write simple enough,
Then no one else can trouble you,
If you didn’t write it down, then at most you missed it;
You wrote it wrong,
That would be a big trouble,
This is why there is such a saying in the medical field: Do more and make more mistakes, do less and make fewer mistakes, and it is good not to do it!
Li Xiaojun has accurately grasped the principle of writing medical records,
I can't write anyway,
Then I won’t write it.
"Teacher Ray"
Seeing that the thunderstorm was suffocating, Li Xiaojun hurriedly yelled.
"Were you on the operating table?"
The thunderstorm is almost dizzy,
He didn't want to think about it, could he write the operation records without being on the operating table?
"exist."
"Then please explain the operation process in detail."
The thunderstorm clipped the medical record card,
He also knew that nothing could be seen on it, and he could only comfort himself that it was probably for the sake of keeping it secret.
"Uh"
Li Xiaojun sorted out his language, and told the process in slobber.
After all, Thundershower understood.
I also understood Li Xiaojun,
Too,
It is really difficult to express the operation record of a new operation method clearly and concisely.
After all, this technique has too many new operations.
For example, the ligation and trocar needle is pulled out of the body to form a fixation,
For example, by moving the position of the needle to achieve the purpose of pulling the appendix,
After recalling the entire operation in my mind, I immediately asked about the patient's situation and got a positive response. At least in a short period of time, it seemed that there was not much difference between the two-hole method and the three-hole method.
Thunderstorm sighed:
This doctor Yu's idea is really a genius!
(End of this chapter)
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