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A work report from a manager to the president of Shijiazhuang Hetaiheng Hospital

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A work report from a manager to the president of Shijiazhuang Hetaiheng HospitalDear president,

I’d like to report to you about my feelings after medical records check.

After a long term check of writing medical record, we have avoided big problems about diagnosis and treatment. The main existing problem is wrong unit (e.g. wrong units of abnormal data on the test report). In fact, this kind of mistake can be completely avoided if our staff are more careful. Therefore, the reason why we emphasis the writing of medical record it that we want our doctors to develop a habit of grasping details.

Why should one be more professional than others? The key is that he or she can grasp the details. For example, during the ward round, the doctor see patients cough. Some of the doctors can find that patients have symptoms of heart failure, while others may ignore that and just give patients antibiotics. Patients with heart failure have severe cough when they are lie on the bed, and cough is always along with fever, itchy and sore throat. Take another example, patient complains about weakness. Some doctor know that this problem is due to arrhythmia, while others just think that patient needs to take a rest. If they can touch the pulse of the patient, they can know the severity of weakness. It is because some doctors ignore these details that patients miss the optimal treatment time!

Or, conversely, wouldn’t our doctors cure patients? Wouldn’t our doctor save patients in the crisis? Do our doctor have no sense of responsibility? Even though you ask ten doctors, none can admit that they cannot cure patients, cannot save patients and lack of responsibility! But what causes we take lightly? It’s habit. That’s because we do have the detail-oriented habit. It is the serious “defect” for a doctor. As long as you have the “defect”, it is no doubt you cannot do a doctor.

Stop here, many people may ask how to develop the good habit. Simply, writing medical record can help you pay attention to the details. A good medical record not only has no errors but also has no doubts. That’s to say, I will find that patients’ all problems get well resolved after reading the medical record. If you can do it, just do it; you can’t do that, ask help from experts; if the disease cannot be solved at our hospital, we will invite other experts in other hospital to deal with problems. A doctor should focus on every problem and solve it. Never give up every possible details!

Many people say what to do if they can’t achieve it at present. This needs a department to help us develop this habit of paying attention to details. This department is just supervisory personnel of medical record including the medical department, record room and medical record review group. Now, we must understand why these departments run down a convict for questions in medical record. It is just helpful for us to develop the habit of concerning details.

It is quite lucky for us to live in this hospital. General hospitals turn a blind eye to their patients’ medical record. Different from them, we demand our doctors to concentrate their efforts on medical record again and again. At present, you may feel this is quite annoying, these people are unreasonable and they are stumbling block for you. However, you will find it is just these people who make you achieve your career.

Achieving your career means achieving the career of our hospital. We want to develop a brand new hospital that doesn’t appear in the past. One hospital really cares the medical details, shows therapeutic effects and takes their patients into consideration.

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