After dinner, there were only 5 interns who came to the 12th floor to listen to Li Min talk about how to write a medical record, and not all of them were interns in trauma surgery.Lu Wenkai explained to Li Min embarrassedly: "Teacher Li, when I went back at noon, they all went out shopping, I left a letter to the leading teacher, and also asked the students in the dormitory to tell me. ”"It's okay, just talk about a few people.There's not much content either.,When I encounter it, I'll just say it's for you to remember.。
”Li Min didn't care who came, originally she only told Kevin Lu that one thing was enough."
How to write a medical record, you have already passed the exam in diagnostics.What I want to emphasize today is that in clinical practice, when writing concretely, we should not be afraid of verbose and irritable.Kevin Lu, show your classmates the record of the course of illness that you wrote earlier that I replaced and the draft you typed in the morning. ”Several classmates read Kevin Lu's two manuscripts."
The one that was replaced is a little vague, if it is a normal situation, I mean that the patient does not have any abnormalities after surgery and is discharged safely, the people in the medical record room will not look very carefully, and they can be mixed up.However, in the unlikely event that any problems arise after the procedure, this record of the course of the disease will not stand up to scrutiny.If the medical department asks you, or if the patient finally goes to court, and they ask you, when did the wound show signs of infection after surgery, what was the initial length of redness and swelling, and what did you do to treat the wound?
Kevin Lu, how do you answer?
”Kevin Lu was a little confused, he didn't expect to use his replaced disease course record as an example."
Now is for you to think back to the day before yesterday, and you hesitate.If it is a case that is more than half a year old, do you dare to guarantee that there is no conflict between what you have in your mind and the actual situation?
Once you can't explain it clearly, you will push yourself to the position of being responsible.Whether it is a technical accident or a liability accident, our young doctors who are just starting out can't afford to carry it, and they can't carry it. ”"So when we describe the wound, the first is to tell the truth, and the second is to be detailed, and the more detailed the better.If the wound on the first day is vague and the second day is a little less or not remembered, then on the third day the wound is red and swollen or worse, and we may not be able to explain why the wound has changed in this way. ”"Postoperative patients are required to write a record of the course of the disease for three days in a row, and if the situation is not good and something special happens, it is necessary to write it down in a timely manner, rather than sticking to the number of records once a day, and it is not impossible to record several times a day.It should be kept until the patient's condition improves and stabilizes, and then the diary can be separated.It's not just for the patients, for the senior doctors, for the examination of the medical record room, but for ourselves.Kevin Lu, take the liver repair after our tube and the partial intestinal resection to show your classmates the course of the disease. ”Li Min waited for them to pass on the two records of the course of the disease and asked, "Do you think that the situation of these two patients is vivid and similar to that of your own participation in management?"
”Several students nodded."
That's why I say that the best record of the course of the disease is one that allows the person who is looking at it to form the evolution of the course of the disease in their minds.Do you understand?
”Li Min and other interns reacted to her and continued: "For such an infection case, in addition to carefully recording the general state, the wound condition seen during the dressing change, whether the body temperature is consistent with the wound performance, whether the heart rhythm changes with the body temperature, whether the blood Rt in the laboratory is consistent with the wound condition, what kind of treatment our clinical doctor has done, and whether there is a reaction from the senior physician, it is important to completely record the opinions of the senior physician." ”"It's best to include breathing.Don't make a general statement that you're generally in good shape. ”Li Min waited for a few students to finish memorizing before he continued: "Don't get it out, the postoperative wound has suppurated, the body temperature is 39 degrees, the heart rhythm is 66 times, and even worse, it is also written that the patient is generally in good condition and his vital signs are stable."
Kevin Lu, know why?
”Kevin Lu thought for a moment and said, "Body temperature 39 °?
The patient's basal heart rhythm should be recorded in the medical record, right?
At this time, the actual heart rate should be around 100 beats. ”"Can you be more detailed?"
Li Min saw that some students didn't follow, so he asked.Another student added: "For every degree of body temperature increase, an adult's heart rate will increase by 12-18 beats, and the heart rate should be around 100 beats."
For every degree of body temperature rises, breathing will speed up 3-4 times, and in the case of shortness of breath, it can no longer be said that the general state is good and the vital signs are stable. ”"What if the heart rate is really 66 beats at this time?"
One student hesitated to reply, "Is it time to suspect shock or increased intracranial pressure?"
”"Yes.It's time to be suspicious.Shock is usually an increased heart rate.But this 66 times at a temperature of 39 degrees is definitely not a stable vital sign.If the condition deteriorates, taking the replaced medical record to court, it can only prove that he did not rescue the shock patient in time. ”Lu Kaiwen looked ashamed, and carefully put away the medical record paper that Li Min had replaced, which was almost full.Several students listened very attentively.Li Min looked at the time and said, "That's it for tonight."
You all go back and check the record of your illness that you wrote this week.If I go back and read the book, I will see under what circumstances there will be a disease with an increase in body temperature and a corresponding change in pulse.If the patient's temperature is 39 degrees and he has a pulse of 66, we should consider that he has some underlying disease and did not go for a check-up after the operation. ”A few students were a little stupid for a while.Li Min threw a summary to them: "Patients will not get sick according to textbooks, and they have underlying diseases in their bodies, or have underlying diseases that they do not know about, which are the most common clinical obstacles to efficacy." ”Chen Wenqiang's family of three didn't come tonight, and after telling a few interns how to write a record of the course of illness, Li Min closed the door of the duty room and quietly read books and made papers inside.* In the cafeteria, Li Haoran looked at Sister Fen helplessly.This woman is in her forties, why is she working so roughly?
He had no choice but to stop her first."
Sister Fen, you have to peel off the dead skin of this onion, otherwise the person who gets the stuffing and eats it will give an opinion.And these good parts, you can't just throw them away, you should tear off the dead skin and keep the good ones. ”Sister Fen threw things away angrily, stalked her neck and said, "I always do this at home. ”Li Haoran said unyieldingly: "Our group has cost accounting, and you will increase the cost by doing this."
This is a job where everyone earns money to support their families, and they have to be budgeted carefully.You can choose to change or go. ”Sister Fen was panting, she wanted to take off her apron and fall on Li Haoran's face, but when she thought of what her father said to herself, she couldn't help but be discouraged.Sister Fen's subtle change in momentum was keenly captured by Li Haoran, and he softened his face and said, "You make these onion skins according to my requirements, hurry up, and wait over there to use them." ”"Hmm."
Sister Fen sulked her head and cleaned up the onion skin that was thrown away and the onion with dead skin in the basin little by little according to Li Haoran's request, and a young man over there immediately took the basin away."
Sister Fen, you're so slow, I'm too late."
Another female worker came over and said, "Sister Fen, you have cleaned this place." ”Sister Fen slowly picked up the broom and pinch of the handful."
Do you know how to make buns?""
Not really.""
Where's the pancake?""
Not really."
The woman sighed, "Then what are you going to do in our group?"
”"Didn't you assign me to come and wash the vegetables?""
Our group only prepares the wrong meal for the doctors and nurses on shift, how can there be so many dishes for you to wash?
Forget it, you go and peel the potatoes today. ”Sister Fen said dissatisfied: "Didn't you say that you only make pies and buns at night?"
Why do you still need me to shave potato skins?
”The woman turned her face and was furious, and before she could shout, Li Haoran shouted at him: "Sister Sun, pay attention to your attitude of speaking, we are comrades in a group, and we must all be in a good mood to do good things." ”The woman looked back and said, "I see." ”Then he turned his head to Sister Fen and said, "I'll do what I arrange you to do first."
No one is idle, you have so many words there?!
”Then Sister Sun neatly picked up a pot of potatoes and brought it over, put it on the ground and said to Sister Fen: "You have scraped all the skins of this pot of potatoes, hurry up, wash it and call me."
Team Leader Li, can we make a fried shredded potato as a side dish in a while?
”"You wash ten or eight sharp peppers and cut them into thin strips, and I'll make a hot and sour shredded potato.Pick a few better tomatoes and make a tomato egg soup with buns.Xiao Wang, take a look at the mung bean soup pot and take out the mung bean skin on it. ”A young man answered the call.Sister Fen was very angry, but looking at the six people in this group, no one was busy with their idle hands, hearing the food that Team Leader Li was talking about, thinking of eating such a dinner by herself for a while, she felt a little more comfortable, lowered her head and began to scrape the potato skin.* Li Min went to the bathroom after making a set of rolling papers, and when he came back, he met the interns of Dr.
Liu and the interns of the general surgery department on the night shift, and the jute from the anesthesiology department followed behind them, and a young boy who was more than ten years old and awake was lying on the flat car.Li Min asked curiously: "What surgery?"
”"Acute purulent appendicitis."
Jute replied."
Oh.How do you accept us?
Shouldn't I be sent to a pediatric clinic after surgery?
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”"Teacher Liu said that he is eleven years old, can clearly express his wishes, and can live in our department."
Li Min nodded, and went back to the house to continue studying without asking too much.* The sky was bright, Li Min saw that the time was almost six o'clock, changed his clothes and prepared to go out for a run.Suddenly, a shrill cry came from the corridor on the 12th floor."
Oh my God!
Oh my son. ”This cry is so scary!
Li Min, who was so frightened that he just opened the door and was about to go out, subconsciously closed the door first.She touched her chest and calmed down for a moment, immediately took off her white coat from behind the door, opened the door as she wore it, and shouted to the nurse's duty room: "Who is on the night shift, hurry up and see what's wrong." ”As soon as the words fell, I saw the nurse Sister Fang coming out of the small ward and running to the office at a speed of 100 meters, and Li Min was worried that she would fall.Sister Fang's usual clumsy and lazy appearance was gone, and the expression on her fat face that had not moved for 10,000 years had been replaced by a look full of worry.When she saw Li Min, she immediately shouted, "Doctor Li, go to ward 12 and take a look, that kid is no good."
I had appendicitis surgery last night, and I immediately asked Dr.
Liu to come up. ”"Okay."
Li Min took the door, took out a stethoscope from his pocket and ran to ward 12.The kid was fine after surgery last night, why can't he do it?
Li Min entered ward 12 and saw that the child was living in a bed against the wall in the ward, and his parents were standing in front of the bed.When the child's father saw Li Min, he immediately shouted, "Hurry up and call your doctor." ”"I'm the doctor of this department, you get out of the way and let me see the child."
But in his anxiety, the child's father couldn't listen to Li Min's words at all, so he pushed Li Min out with his hand.He only said repeatedly, "Call your doctor." ”In the stalemate, Dr.
Liu ran up, and when he saw Li Min, he asked, "How is the child?"
”"His father wouldn't show me."
When the child's father saw Dr.
Liu, he immediately rushed over and grabbed his hand and said, "Xiaowei, you are quick, look at my son."
His mom just told him to get up and wipe his face, and as soon as he sat up, his nostrils were bleeding, and then he was pumping on the ground. ”Dr.
Liu threw himself in front of the bed and pulled the mother who was holding the child away."
Get out of the way and let me see the kid."
Li Min followed behind Dr.
Liu, saw the convulsive child, and immediately handed over the stethoscope in his hand.Dr.
Liu lifted the sheet and opened the child's vest to listen to the heartbeat.After a few moments, he put the stethoscope around his neck, put his hands on the child's chest, and began to administer first aid.Li Min rushed to the door, lowered his voice into the corridor and shouted, "Sister Fang, quickly push the ambulance." ”Then she turned around and went back to the child's bedside, knocked the parents who were in the way open, turned on the oxygen knob at the bedside, grabbed the towel at the bedside to wipe the pink liquid from the child's nostrils, and quickly put the oxygen tube on the child and inserted it into the nostrils.He took out the gauze from his pocket, pinched the corner of the child's jaw with both hands, pinched the child's mouth open, and saw that the tongue did not fall back, and then let go of his heart.I wanted to turn to the end of the bed again, but my parents who were in the way blocked the way again.Li Min couldn't help but yell: "You two stand over there."
Way. ”Fortunately, the child's father still had a little sense and pulled the child's mother aside.Li Min shook the head of the bed down.Sister Fang also pushed the ambulance in.But in just two or three minutes, Li Min and Dr.
Liu realized that the child was hopeless.
※※※※※※※※※※※※※※※※※※※※Every death is ...... () The distance is a bit far