What your medical charts might actually say
Posted: March 5, 2004, 3:45 pm
Actual Sentences Found on Patients' Hospital Charts (Proves
that those medical folks are right on top of things. When you're
pushed for time, it is so easy to write a note and not take the
time to reread and correct.)
1. She has no rigors or shaking chills, but her husband states
that she was very hot in bed last night.
2. Patient has chest pain if she lies on her left side for over
a year.
3. On the second day the knee was better, and on the third day
it disappeared.
4. The patient is tearful and crying constantly. She also
appears to be depressed.
5. The patient has been depressed since she began seeing me in
1993.
6. Discharge status: Alive but without my permission.
7. Healthy appearing decrepit 69 year old male, mentally alert
but forgetful.
8. The patient refused autopsy.
9. The patient has no previous history of suicides.
10. Patient has left white blood cells at another hospital.
11. Patient's medical history has been remarkably insignificant,
with only 40 pound weight gain in the past three days.
12. Patient had waffles for breakfast and anorexia for lunch.
13. Between you and me, we ought to be able to get this lady
pregnant.
14. Since she can't get pregnant with her husband, I thought you
might like to work her up.
15. She is numb from her toes down.
16. While in ER, she was examined, X-rated and sent home.
17. The skin was moist and dry.
18. Occasional, constant infrequent headaches.
19. Patient was alert and unresponsive.
20. Rec tal examination revealed a normal size thyroid.
21. She stated that she had been constipated for most of her
life, until she got a divorce.
22. I saw your patient today, who is still under our car for
physical therapy.
23. Both breasts are equal and reactive to light and
accommodation.
24. Examination of genitalia reveals that he is circus sized.
25. The lab test indicated abnormal lover function.
26. The patient was to have a bow el resection. However, he took
a job as a stockbroker instead.
27. Skin: somewhat pale but present.
28. The pelvic exam will be done later on the floor.
29. Patient was seen in consultation by Dr. Blank, who felt we
should sit on the abdomen and I agree.
30. Large brown stool ambulating in the hall.
31. Patient has two teenage children, but no other
abnormalities.
that those medical folks are right on top of things. When you're
pushed for time, it is so easy to write a note and not take the
time to reread and correct.)
1. She has no rigors or shaking chills, but her husband states
that she was very hot in bed last night.
2. Patient has chest pain if she lies on her left side for over
a year.
3. On the second day the knee was better, and on the third day
it disappeared.
4. The patient is tearful and crying constantly. She also
appears to be depressed.
5. The patient has been depressed since she began seeing me in
1993.
6. Discharge status: Alive but without my permission.
7. Healthy appearing decrepit 69 year old male, mentally alert
but forgetful.
8. The patient refused autopsy.
9. The patient has no previous history of suicides.
10. Patient has left white blood cells at another hospital.
11. Patient's medical history has been remarkably insignificant,
with only 40 pound weight gain in the past three days.
12. Patient had waffles for breakfast and anorexia for lunch.
13. Between you and me, we ought to be able to get this lady
pregnant.
14. Since she can't get pregnant with her husband, I thought you
might like to work her up.
15. She is numb from her toes down.
16. While in ER, she was examined, X-rated and sent home.
17. The skin was moist and dry.
18. Occasional, constant infrequent headaches.
19. Patient was alert and unresponsive.
20. Rec tal examination revealed a normal size thyroid.
21. She stated that she had been constipated for most of her
life, until she got a divorce.
22. I saw your patient today, who is still under our car for
physical therapy.
23. Both breasts are equal and reactive to light and
accommodation.
24. Examination of genitalia reveals that he is circus sized.
25. The lab test indicated abnormal lover function.
26. The patient was to have a bow el resection. However, he took
a job as a stockbroker instead.
27. Skin: somewhat pale but present.
28. The pelvic exam will be done later on the floor.
29. Patient was seen in consultation by Dr. Blank, who felt we
should sit on the abdomen and I agree.
30. Large brown stool ambulating in the hall.
31. Patient has two teenage children, but no other
abnormalities.
