Tuesday, June 5, 2007

Hospital Chart Bloopers

Actual writings on hospital charts:

  • She has no rigors or shaking chills, but her husband states she was very hot in bed last night.

  • Patient has chest pain if she lies on her left side for over a year.

  • On the second day the knee was better, and on the third day it disappeared.

  • The patient is tearful and crying constantly. She also appears to be depressed.

  • The patient has been depressed since she began seeing me in 1993.

  • Discharge status: Alive but without my permission.

  • Healthy appearing decrepit 69 year old male, mentally alert but forgetful.

  • The patient refused autopsy.

  • The patient has no previous history of suicides.

  • Patient has left white blood cells at another hospital.

  • Patient's medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.

  • Patient had waffles for breakfast and anorexia for lunch.

  • She is numb from her toes down.

  • While in ER, she was examined, X-rated and sent home.

  • The skin was moist and dry.

  • Occasional, constant infrequent headaches.

  • Patient was alert and unresponsive.

  • Rectal examination revealed a normal size thyroid.

  • She stated that she had been constipated for most of her life, until she got a divorce.

  • I saw your patient today, who is still under our car for physical therapy.

  • Both breasts are equal and reactive to light and accommodation.

  • Examination of genitalia reveals that he is circus sized.

  • The lab test indicated abnormal lover function.

  • The patient was to have a bowel resection. However, he took a job as a stock broker instead.

  • Skin: somewhat pale but present.

  • The pelvic exam will be done later on the floor.

  • Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen and I agree.

  • Large brown stool ambulating in the hall.

  • Patient has two teenage children, but no other abnormalities.

Text found HERE

4 comments: