Related Posts:
- My Last Day In The Department of Obstetrics And Gynaecology
- Surviving On-Night In The Gynaecology Ward As A House Officer In Sarawak General Hospital – Housemanship Diaries
- Surviving On-Night In The Postnatal Ward (Maternity 1 & 3) As A House Officer In Sarawak General Hospital – Housemanship Diaries
- Surviving On-Night In The Antenatal Ward (Maternity 2) As A House Officer In Sarawak General Hospital – Housemanship Diaries
- The Types Of Wards In The O&G Department Of Sarawak General Hospital – Housemanship Diaries
- Being An O&G Operating Theatre House Officer – Housemanship Diaries
- The Labour Ward, O&G Department – Housemanship Diaries
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Perhaps I had been lucky? Perhaps I have been “let off the hook” multiple times (which I know is true). But I have made multiple mistakes and if there is one thing I know, I am still not competent enough but I take pride in the fact that I’ve tried and I am still pushing forth through the journey.
My first every explanation letter occurred while I was in the Obstetric and Gynaecology Posting. I forfeited my off day on that day and was called back to assist in Maternity 2 as one house officer took emergency leave and there were lack of house officers on duty.
The job scope of Maternity 2 involves monitoring the foetal heart condition on the CTG (cardiotocograph), attending to any acute cases such as patients complaining of contraction pain or spontaneous rupture of membrane (SROM) or in short “their water broke”.
I was towards the end of my shift, around 6:55pm when a staff nurse informed me that there is a deceleration on the CTG monitoring.
I attended STAT. To my surprise, there were significant episodes of decelerations on the CTG and I proceeded to check the opening of her cervix. It was only 3cm. The criteria was for the cervix to be at least 5cm before calling labour ward to send the patient downstairs.
I immediately took picture of the CTG monitoring, took the case note and rushed downstairs to find any medical officer on call to present my case. However, there were no other medical officers present at that time except for the Registrar who was writing her review. Considering that the patient’s baby is in acute foetal distress, I explained to her that I had to present this case.
Upon presenting my review, I was asked a few questions regarding her admission which I did not know and proceeded to flip the case note to answer her.
She then commented on my lack of insight on the patient’s case and inability to document my findings first before referring. I agree. I should’ve documented first.
However, I have a tendency to act first before thinking, thus, my first instinct was to run and inform STAT before digesting her antenatal issues and progress in the ward.
I was saved from the continuation of her comment by another fellow medical officer, the very same one who was with me when I experienced a case of cord prolapse during my night shift in Maternity 2.
Upon reviewing the patient, the patient mentioned that her water broke around 4pm.
Now, this was a real mistake on my part. At 4pm, the staff nurse informed me that this particular patient informed that her water broke to which I attended STAT.
Upon my assessment, there were no leaking liquor, cough impulse was also negative and her bedsheet was not wet. However, I did not document it down.
Thus, when she was assessed by the medical officer, that was when her water broke, there was obvious flooding and the medical officer proceeded to check for any entry at 4pm. She then called the Registrar to inform regarding this case and told that initially at 4pm, the patient complained of leaking liquor to which I claimed there wasn’t. However, there was no documentation.
I was then asked to hand in an explanation letter by 8am the following morning to which I did by that night shift.
Documentation is extremely important because should a case be brought to court in the future, the documentation serves to save myself as the patient’s case note serves as a legal document.
Thus, if you are having trouble like me in terms of documenting prior to acting, I totally understand. However, just document first if you can!
Related Posts:
- My Last Day In The Department of Obstetrics And Gynaecology
- Surviving On-Night In The Gynaecology Ward As A House Officer In Sarawak General Hospital – Housemanship Diaries
- Surviving On-Night In The Postnatal Ward (Maternity 1 & 3) As A House Officer In Sarawak General Hospital – Housemanship Diaries
- Surviving On-Night In The Antenatal Ward (Maternity 2) As A House Officer In Sarawak General Hospital – Housemanship Diaries
- The Types Of Wards In The O&G Department Of Sarawak General Hospital – Housemanship Diaries
- Being An O&G Operating Theatre House Officer – Housemanship Diaries
- The Labour Ward, O&G Department – Housemanship Diaries
- 8 Best Advices I Will Remember For The Longest Time – The Orthopaedic Posting
- My Second Posting During Housemanship – Obstetrics & Gynaecology
- I Survived 26 Days Of Tagging In O&G – Housemanship Diaries
The Theoretical Doctor 