Paperwork is one of the most boring things in the life of a resident doctor. But it one of the most critical part of the patient’s management. It forms the backbone of one’s defence should the patient sue the doctor for any reason. Hence we train the resident doctors quite rigorously in paperwork. This year I started skills workshop for them, and put one session on paperwork. All sessions were compulsory for all of the resident doctors. However some of them missed some, because of illness or some other reason for being absent. Even without any training, filling up the indoor paper should not be difficult. There are printed headings on the case paper. One just has to fill in the blanks. Should not require too much intelligence and much training, one would think. Alas, no! One such resident doctor had completed a patient’s indoor case paper as follows.
Provisional diagnosis: Vaginal hysterectomy was done.
Final diagnosis: by Dr ‘so and so’
Operation performed: assisted by Dr ‘so and so’
Complications: and Dr ‘so and so’
Disaster: spinal anesthesia by Dr ‘so and so’
(I have put ‘so and so’ in places of names of doctors involved to protect their identity.)
The resident doctor felt that the space provided for putting the name of the operation, the names of the operationg surgeon and his assistants and the anesthetist was not sufficient. So she used up the space available above and below the heading ‘Operation’, breaking up all that information into so many more lines, without any regard to the information that should have been entered there but was not and could not ever be thanks to her efforts. I read out the stuff she had written on my ward round, and all the other residents listened with boredom until I read Disaster: spinal anesthesia by Dr ‘so and so’, at which point they burst out laughing. Perhaps the statement had a ring of truth to it. The poor anesthetist is not aware how his work has been appreciated by our resident doctor.
