In praise of the hole punch


I once worked with a consultant who had worked with a consultant who, I was told, used to take patients’ case notes and dangle them by the spine. He would look disdainfully at the loose sheets of paper that fell to the floor and walk away muttering, ‘File them!’ Terribly arrogant, but I can see where he was coming from.

During their first 72 hours in hospital patients tend to move quickly, from the emergency department via an admissions unit to their allocated ward. Every professional who interacts with the patient writes an entry and files it. When ward rounds happen hastily and the highly educated ‘scribe’ rushes to complete the summary before his or her team moves on, this step is often missed. The file may be a temporary plastic one, without a clasp, or an ungainly brick stuffed with tattered and fading correspondence from the 1970s and 80’s. Where the new notes should go nobody really knows, and the patient is not in one place long enough for that essential person, the ward clerk, to sort it all out.

So I come to review a patient. I find the folder, a conventional buff set. The new papers have been serially slipped between the front cover and the first page. There are about twenty sheets, in some disorder. They are like a pack of cards, thrown down and swept up from the carpet – some are upside-down, some are back to front. The narrative is broken, the recorded facts are scattered. Crucial clues, be they clinical signs, blood results or subtle observations made by nurses… they are all there, waiting to be read, noticed and integrated into the whole. But until they find physical order, and until that order is processed by a medical consciousness, be it a consultant or another member of the team, they are useless.

I am not a tidy person by nature, but when it comes to notes I get pernickety. I have spent significant periods bent over notes, de-shuffling and finding the right place for various documents. In order to file paper, one needs a good hole. Holes are important, and I have made a study of them. Raggedy holes, made by poking those plastic binding spikes through the paper, are no good… the edges are soft and predispose to wear and tear. In a few days those sheets drift free and disappear. Sharp pencils make decent holes, but who carries a sharp pencil nowadays?! One can reinforce raggedy holes with bits of dressing tape folded over the page’s edge, or, in desperation, sticky name labels folded in the same way… anything, to reinforce the hole!

But the best way to make holes is with an industrial, unbreakable, unconquerable hole punch. How many times have I roamed the wards for such a prize? They scythe through paper with a mighty, emphatic press, leaving a true core of sharp-edged holes. And then… then the paper can be filed! All that the patient has given, their recollections and complaints, and all that has been unearthed during subsequent investigation, some of it legible, some not, lies ready to tell the story.

I feel better now.




One comment

  1. Ha !! So true. We are blessed with powerful hole punches on our wards but more important is to give the floating papers some stability with a treasury tag to hold together the latest acute admission – another simple joy ! Because there usually isn;t time on the round to start undoing the mammoth wodges of fat notes precariously secured with a weedy plastic contraption in order to insert the latest admission, I have taken to having the latest admission at least tied together in the front. In some wards we have separate files for the latest admission – much easier to handle but as you point out with a risk of forgetting to trawl through the previous history of admissions and letters and missing vital clues. Our medical notes are an archaic system – can’t believe that the people who have invented all the current craze of fold-up picnic chairs etc can’t design some sort of efficient clamped folder.. although I understand those hospitals which are now completely computerised are doing well.


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