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作者:黃品叡
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我要每天都準時下班|上篇:病歷書寫
「工作是一時,人生是一輩子。」這是我很喜歡的一句話。記得剛當Intern的時候很衝,剛踏入臨床充滿新鮮感,彷彿光是多呼吸些醫院的空氣,自己就會變得更強些。6,7點下班是常態;PM off回家睡個覺,晚上再回醫院打病歷,反正宿舍就在樓上,很近。
但日子久了,值班對身體的影響慢慢顯現,逐漸地沒有精神。晚下班會惡性循環,加上值班更是雪上加霜。忘了從甚麼時候開始,看到指針指向下午五點半,就會匆忙地收拾東西,準備回家。小孩出世之後,本來在家的時間就不多,更希望能夠準時下班,陪陪自己生命中重要的家人。
以下分享四個實用小技巧,希望幫助大家提升臨床作業效率,準時下班:
Table of Contents
Toggle▌如何兼顧病歷完整性及效率,完成病歷
- Admission note / Discharge note 寫作模板
- Progress note:SOAP/PAP 寫作差異
- Weekly summary 寫作重點
- On / Off-service note 寫作重點
- Pre-OP / OP / Post-OP 寫作重點
- Duty note 寫作重點
下篇講醫囑、交班、查房
▌如何快速且完整不遺漏的,開完Order
- 常見Routine開立方式
- 常見ICU Routine開立方式
- 額外補充:Pre-OP order
▌如何快速且完整的交班
- 交班簡易分級:黑紅黃綠
- 各級病人照護和交班重點
- 三種類型的交班模式和要點
▌如何快速在查房前看完病人和Data
- 查房重點解析
- 如何快速看Data
- 三種查房範例示範
完整版講義下載|年度會員專屬:點此前往
更完整的病歷寫作教學,可以參考 Gem Wu 吳懷珏醫師 分享的 內科clerkship要怎麼approach (2):寫入院病歷 Admission Note 、接病人
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回地圖首頁:PGY職前必修21堂課
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回地圖首頁:PGY職前必修21堂課