Chapter 62： Medical record

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

The family members of the patients gathered together suddenly became happy, and several women were crying with joy.

Xun Huo's army reassured two more sentences, and then left after making a doctor's order.

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

Clan Huo also sighed softly, nodded and smiled at Ling Ran coming out from behind.

Ling Ran nodded likewise, and went in the opposite direction.

Today's operating rooms are all multi-functional. The interior of the operating room is the same. There are also many roads to leave. Patients are keeping the one closest to the ward.

Lu Wenbin followed Ling Ran steadily, feeling like it was the first time that people went to an Internet cafe.

The little joy, the little tangle, the little regret, the little expectation make him like a little Teddy. I really think there is something now that I can make a mess of myself.

"Dr. Ling, what are we going to do next?" Lu Wenbin was so anxious that he couldn't wait to do another 300 cases of tang law and became a well-known figure in one fell swoop.

"Teach me to write a medical record." Ling Ran replied, instantly pulling Lu Wenbin from Kepler 76B-Albert Einstein to the earth.

"I teach you to write medical records?" Lu Wenbin repeated again, and then suddenly realized: "You haven't started writing medical records since you just started your internship?"

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

"What have you done?"

"Debride and suture, stop bleeding with bare hands, and then do the tang method." Ling Ran counted it in turn and said: "The emergency department was the first department in my rotation practice."

Lu Wenbin looked at Ling Ran, his mood was extremely complicated.

The first half of the sentence sounds, Ling Ran seems to have done everything the surgeon should do.

After hearing the second sentence, I was convinced that she didn't do anything.

"Write a medical record after debridement and suture. Have you written a simple version?" Lu Wenbin was a little curious.

"Wrote several times," Ling Ran said.

"How many times have I written it? What about the rest of the medical records? Did Dr. Zhou write it?" Lu Wenbin felt that Dr. Zhou's laziness was wrong, and in the character of Dr. Zhou, it was impossible to do such a thing.

Ling Ling also gave a strange glance at Lu Wenbin and said, "There are other interns to help write."

In the days when he was in the treatment room, he happened to encounter a factory explosion. Everyone couldn't get too busy. He was able to sew up, and he would naturally get started. Other interns who did n’t have access would be responsible for writing, writing medical records, and so on.

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

什么 样 What kind of life did he have during his internship? For a whole year, sewing a skin is like New Year.

Of course, the so-called gifted interns did get more opportunities during the same period. Those who debride as soon as they learn will be able to sew up a seam, go into the operating room without mistakes, pull hooks without being scolded, **** and cooperate well, and close the abdomen. Classmates who did not bleed, more or less, got an appendix, a hemorrhoid, and a circumcision. Opportunities like leather.

However, Lu Wenbin really did not expect that the gap in talent could be so large.

Lu Wenbin grinned and said, "I didn't expect that interns would have interns to fight."

Aside, Nurse Wang, who was reluctant to be separated from Dr. Ling, looked at the talking inpatient Lu Wenbin in surprise ...

Lu Wenbin suddenly came to his senses, yeah, Ling Ran already has a resident doctor to fight, what is the intern to fight what is more-more sadly, the resident who gave Ling Ran the fight is himself.

Lu Wenbin quietly came to the office with Ling Ran, silently turned on his computer, silently landed on his electronic workstation, and pointed to a long line of words, saying: "Now you need to complete the summary before the operation, the hospital medical records, before the operation Discussion records, surgery records, and long-term and interim orders ... "

"What we did today, you can fill in the operation record sheet, you click here." Lu Wenbin gave up the position to Ling Ran.

The head of the operation record list is the patient's name, gender, department, bed number, operation date, etc., followed by a preoperative diagnosis consisting of a few sentences, an intraoperative diagnosis, the content of the operation, the surgical staff, the method of anesthesia, Anesthesia staff, etc ...

Although the record form is electronic, everything can be printed directly and becomes a paper medical record, and the content of it is as complicated as the previous paper medical record.

"The template looks like this, it's actually quite simple ..." Lu Wenbin introduced each item.

Asking interns or doctors to write medical records is actually the most often lazy model for residents.

Several batches of interns and doctors come to the department to rotate each year. Therefore, the resident doctors teach people to write medical records every year, and several times.

Lu Wenbin is also somewhat familiar with this, not to mention that there is no complicated module in the medical record system, it is just tedious.

Ling Ran listened carefully, and according to the instructions in the case, crackled up.

"Preoperative diagnosis, the first is the tendon rupture of the thumb, the second is the tendon contusion ..." Ling Ran's diagnosis and course of the tang suture are master-level, all that is needed is the official document writing of the familiar case.

Lu Wenbin smiled secretly and said two times, "In fact, you can copy and paste ..."

Ling Ran then learned to copy and paste two paragraphs, and then filled out the medical record, only felt uncomfortable, until he deleted it, and then relaxed.

Crackling.

Crackling.

Crackling, crackling.

Pleasant keyboard sound, once again sounded a pleasant sound.

Lu Wenbin just felt uncomfortable.

Copy and paste Dafa, OK? Of course, it ’s okay. After you paste the UU reading book , you only need to modify it once, it can be said to be fast and good. Therefore, despite the old stubborn emphasis on hand beating, the little doctors never listened.

Lu Wenbin always believes that copying and pasting is the most normal way to write medical records. It is a new method under new technology. No one will ask for help.

He did not expect that Ling Ran chose the hand-to-hand mode without hesitation.

And also hit fast.

I do n’t seem to need much thought.

However, a case can be tens of thousands of words, and it can be tiring.

Lu Wenbin was a little naive who wanted to laugh at Ling Ran, but couldn't laugh.

People have talent and technology that are valued by leaders. They are still fighting cases. What qualifications do they have to laugh at?

Lü Wenbin admired and looked at Ling Ran's moving fingers with admiration, and gained a new understanding of his own medical path.

At the same time, Ling Ran was also sighing with emotion: copying and pasting the article after modification was heresy, just like the meat dumplings in dumplings. Fortunately, it is not necessary.

Ling Ran finished writing a paragraph and then writing another paragraph, the speed is not slow.

Medical records are not particular about writing, as long as you write things down and write them clearly, you can list them, you do n’t have to contact them, you can understand them. In fact, if the requirements of the superior doctor are not strict, you can write and write. Passed.

The single skill book obtained by Ling Ran completely acquired the skills of the tang method, and the medical records of writing the tang method were still master-level and also the operation performed by his main knife. As long as he checked some preliminary examination data, it seemed even more Easy.

After writing, check and fill in the new form.

I don't know how long, the nurse Wang Jia came quickly, admiring the back of the male **** for two seconds from the back, and said, "Dr. Ling, the previous patient can make a fist slightly."