Chapter 62: Medical Records
Huo Congjun walked out of the door of the operating theater and said what the patient’s family, who were waiting anxiously, wanted to hear the most. “Mister Tang’s surgery was a huge success.”
The patient’s family immediately became happy as they stood huddled together. A few women even shed tears of joy. Huo Congjun then comforted them for a bit and gave them some medical advice before he left.
Meanwhile, as his family returned to the ward, the patient was also pushed back there on the gurney.
Huo Congjun exhaled softly and nodded at Ling Ran, who was coming out of the operating theater behind him, with a smile. Ling Ran nodded as well before walking towards the opposite direction.
All operating theaters nowadays had multiple purposes, with surgical suites of the same layout. There were also various routes to leave the operating theaters, the patient’s family usually waited at the ones nearest to the wards. The doctors tried to avoid taking those routes whenever possible.
Lu Wenbin walked gladly and diligently behind Ling Ran. He felt like he was following someone to an internet cafe for the first time.
He felt rather joyous, torn, regretful, and hopeful—like a toy poodle. He really wished that there was something he could simply fiddle with right now to release all his pent up energy.
“Doctor Ling, what are we doing next?” Lu Wenbin could hardly suppress the itch in his heart. He could not wait to perform three hundred more surgeries using the M-Tang technique and become renowned in the country overnight.
“You can teach me how to write medical records.” Ling Ran’s reply made Lu Wenbin fall from Kepler-76b—Albert Einstein’s planet—and back to earth in an instant.
“Teach you how to write medical records?” Lu Wenbin repeated what Ling Ran said before suddenly coming to his senses. “You just started your internship and haven’t even started writing medical records?”
“Yeah, I haven’t really written any,” Ling Ran said.
“What have you done then?”
“Debriding, suturing, barehanded bleeding control, and the M-Tang technique.” Ling Ran listed out what he had done one by one and said, “The Emergency Department is the first department of my clinical rotation.
Lu Wenbin gazed at Ling Ran with extremely complicated emotions. It sounded like Ling Ran had done all that a surgeon should do from his first sentence.
However, after he heard the second sentence, Lu Wenbin was certain that Ling Ran had done nothing.
“You have to write medical records even after debriding and suturing, right? The simplified type. Have you written any?” Lu Wenbin was slightly curious.
“A few,” Ling Ran said.
“Only a few? How about the remaining medical records? Could it be that Doctor Zhou wrote them?” Lu Wenbin felt that with Doctor Zhou’s laziness-No, with Doctor Zhou’s personality, it was impossible that he would do something like this.
Ling Ran glanced at Lu Wenbin in puzzlement and said, “There were other medical interns who helped me with writing the medical records.”
There happened to be a factory explosion during one of the few days Ling Ran was at the treatment room, and everyone could hardly catch their breaths. Ling Ran was naturally put to good use since he knew how to suture, and the other medical interns who were of no help were tasked to do menial things such as play second fiddle and write medical records.
Lu Wenbin felt that the world had become rather strange.
What sort of life did he lead as a medical intern? For the entire year, even the opportunity to suture a patient’s skin was as rare as the times New Year’s celebration happened in a year.
Of course, the supposedly talented medical interns in his batch did get more opportunities. The medical interns who quickly learned how to debride and suture wounds, did not commit errors in the operating theater, did not get scolded when retracting the skin, cooperated well with other doctors when aspirating fluid, and did not cause blood to seep out when performing abdominal closures more or less got the chance to perform procedures such as appendectomies, popping hemorrhoids, and circumcisions.
But Lu Wenbin really did not expect talent to make such a big difference.
Lu Wenbin chuckled and said, “I had no idea that medical interns can have other medical interns play second fiddle to them, too.”
Beside them, Nurse Wang, who was reluctant to part immediately with Doctor Ling, looked in astonishment at Resident Doctor Lu Wenbin as he said these words.
Lu Wenbin suddenly came to his senses. ‘True. Ling Ran, a medical intern, already has a resident doctor play second fiddle to him. What’s so surprising about him having other medical interns play second fiddle? It’s even more pathetic that I’m the resident doctor playing second fiddle to Ling Ran.’
Lu Wenbin quietly led Ling Ran to the office, switched on his computer, and logged into his electronic workstation. He pointed at the long row of words and said, “Now, we need to fill up the preoperative summary, admission record, records of preoperative discussions, operative report, and then things such as long-term medical advice and short-term medical advice.
“We can fill up the operative report section with what we did today. Click on this.” Lu Wenbin made room for Ling Ran.
The top of the operative report section was made up of details such as the patient’s name, gender, department, bed number and date of surgery. Next, details such as the preoperative diagnosis, intraoperative diagnosis, content of surgery, personnel involved during the surgery, anesthetics used, and the personnel involved during the anesthetizing process, were summarized in a few short sentences.
Even though the reports were digital, all their content could be printed out directly into hard copy medical reports. The content was also as cumbersome as the ones in hard copy medical reports of the past.
“This is the template. It’s actually quite simple…” Lu Wenbin introduced the sections one by one to Ling Ran.
To let medical interns or housemen write their medical records was actually the resident doctors’ most common way of slacking.
The resident doctors had to teach other people how to write medical records a few times a year, as there would be quite a few batches of medical interns and housemen on rotation in their departments every year.
Lu Wenbin was already quite adept in doing so. Moreover, the medical record system was not complicated to begin with, just purely cumbersome.
Ling Ran listened earnestly. He then started tapping the keyboard according to what was explained.
“The first preoperative diagnosis was the rupture of the tendon of the thumb, and the second one was the contusion of the tendon…” Ling Ran’s knowledge about the diagnoses and courses of disease related to the M-Tang technique was also at Master Level. The only thing he needed to do was to familiarize himself with the documentation style of medical reports.
Lu Wenbin chuckled internally when he looked at Ling Ran and said, “You can actually copy and paste…”
Ling Ran listened to what Lu Wenbin said and copied and pasted two paragraphs. However, his whole body felt uncomfortable when he started filling up the medical record again. He only felt relieved after he deleted the two paragraphs that he copied and pasted.
*Tap, tap.*
*Tap, tap, tap.*
*Tap, tap. Tap, tap, tap.*
The melodic sound of the keyboard echoed joyously again. Lu Wenbin felt uncomfortable from head to toe.
Was the copy and paste method good? Of course it was. You could say that it was quick and good because you only needed to edit the content once after pasting it. Therefore, even though there were stubborn old doctors who emphasized on typing medical records word by word, young doctors never listened to them.
Lu Wenbin had always believed that the ‘copy, paste and edit’ method was the most normal way to write medical records, that it was a new method that resulted from new technology, and that no one would actively go making their lives hard.
But he never thought that Ling Ran would, without hesitation, choose to type the medical record word by word.
…And that he would do so at lightning speed, as though he did not really need to think.
However, it would be very tiring to type a medical record which was a few thousand to ten thousand words or so in length word by word. Lu Wenbin kind of wanted to laugh at how naive Ling Ran was, but he was unable to do so.
‘Ling Ran is still typing his medical record word by word even though he is talented, possesses good skills, and valued by the leader. What right do I have to laugh at him?’
Lu Wenbin watched in admiration and a tinge of emotion as Ling Ran’s hands flew across the keyboard. He suddenly had a new understanding when it came to his medical journey.
At the same time, in his heart, Ling Ran was also overcome with emotions. ‘Essays that are copied, pasted, then edited are totally blasphemous, just like dumplings with meatballs inside. Fortunately, it is not a must.’
Ling Ran wrote paragraph after paragraph at quite a rapid speed. Writing style was not important when it came to medical records, the medical records must just be written in a clear manner. As long as the medical records could be understood, it was alright if they were all spread out or incohesive. In fact, if the senior doctors were not strict, the medical records would pass even if they were just written simply.
Since the Single Skill Book Ling Ran obtained gave him all the skills related to the M-Tang technique, his ability in writing medical records related to the M-Tang technique was also Master Level. Together with the fact that he was the chief surgeon of the operation, he only needed to research some test data for the preface. It was very easy for him.
After completing the operative report section, Ling Ran checked it, and proceeded to the next section.
After an indefinite amount of time, Nurse Wang Jia walked over in quick steps. After admiring Prince Charming from behind for two seconds, she said, “Doctor Ling, the previous patient can already clench his fist a little.”
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