06 / Patient care · Documentation
Write it so 3 a.m. can act on it
Documentation is a clinical skill with a reader: the doctor who was not there. The operative note builder puts three candidate lines in front of you for every field of a real note, one of them is the line a registrar would sign, and ends with your note beside the reference.
Operative note · Laparoscopic cholecystectomy
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You assisted an uncomplicated laparoscopic cholecystectomy for symptomatic gallstones. The registrar hands you the notes: 'Write it up, I'll countersign.'
Pre- and post-operative diagnosis
The other document that matters
The handover frame
Six lines per patient, every shift change, the same order every time. The call-shift simulation ends with this frame in action.
- 1Who they are
- Name-free here, always identified properly in real life: age, admission problem, relevant background.
- 2What was done
- Operation or decision, and when. 'Laparotomy for bleeding at 03:30' tells the day team the whole shape of the night.
- 3Current status
- Trending observations, not adjectives: 'HR settled from 115 to 88' beats 'doing better'.
- 4Active issues
- What is unresolved, in priority order, with what has already been tried.
- 5What is pending
- Bloods due, scan booked, review promised, everything that will otherwise be discovered by accident.
- 6What to do if
- The night's judgement, packaged: 'if the drain exceeds 100 mL/h, call the registrar, theatre is aware'.