When I got into medical school, the first comment a friend made was ‘OMG, you’re going to save lives!”. 

When I became a doctor, the first thing I thought was ‘I might actually save a life this year!”.

I don’t know how many life-saving activities I’ve done in the past four months. Unless you count making coffee for everyone in the morning before the ward round and let’s be real caffeine is a true hero.

However, I have become exceedingly familiar with discharge letters, typing up drug charts and documenting, documenting, documenting. There is so much documenting.

In the NHS, documentation of any and all clinical interaction is the main form of communication. It’s in fact the only way of knowing what your patient has so far gone through, what investigations they’ve had and importantly what other members of the team like the physiotherapist, the mental health team or the nursing staff have contributed to the patient’s care. It’s also the only way I remember weeks later (when I’m writing the discharge letter) what we had actually said and done when the patient first came in.

But no one in medical school actually teaches you ‘how to write in medical notes’. There is no class for hand writing. And let me tell you, some grown-ups really need cursive writing lessons. There isn’t a station in the OSCE for ‘outline the structure of a ward round sheet’. What we do have is on the job learning.

You learn pretty fast to write quick and efficient notes that describe the current situation and help your team members with their job. 

You also learn fast that writing in any colour apart from black is just not done. (Unless you are a pharmacist and then you can write in purple). Underlining means that it’s a really important fact and one must not ignore it. E.g: Writing ‘please do fluid chart’ is so much tamer than ‘please do fluid chart’.

And if you steal someone else’s pen…you’ll quickly become public enemy number 1. 

As a foundation year 1 a lot of the writing becomes my responsibility. Documentation is probably the most tedious part of my day. And definitely one of the most important. I might not be saving lives every day but what I write  and how I write helps others save lives now and in the future. And that’s a pretty cool thing if I’m honest.