A collection of documentation statements actually found on patient’s charts during a recent review of medical records. These statements were written by various health care professionals including (we are afraid) a doctor or two at several major hospitals:
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The baby was delivered, the cord clamped and cut and handed to the pediatrician, who breathed and cried immediately.
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Exam of genitalia reveals that he is circus sized.
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The skin was moist and dry.
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Rectal exam revealed a normal size thyroid.
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She stated that she had been constipated for most of her life until 1989 when she got a divorce.
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The patient was in his usual state of good health until his airplane ran out of gas and crashed.
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I saw your patient today, who is still under our car for physical therapy.
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The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week.
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Bleeding started in the rectal area and continued all the way to Los Angeles.
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She is numb from her toes down.
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The patient had waffles for breakfast and anorexia for lunch.
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Exam of genitalia was completely negative except for the right foot.
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While in the emergency room, she was examined, X-rated and sent home.
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The lab test indicated abnormal lover function.
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The patient was to have a bowel resection. However he took a job as a stockbroker instead.
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Occasional, constant, infrequent headaches.
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Coming from Detroit, this man has no children.
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Examination reveals a well-developed male lying in bed with his family in no distress.
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Patient was alert and unresponsive.
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When she fainted, her eyes rolled around the room.
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She has no rigors or shaking chills, but her husband states she was very hot in bed last night.
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Patient has chest pain if she lies on her left side for over a year.
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On the second day the knee was better, and on the third day it disappeared.
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The patient is tearful and crying constantly. She also appears to be depressed.
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The patient has been depressed since she began seeing me in 1993.
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Discharge status: Alive but without my permission.
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Healthy appearing decrepit 69 year old male, mentally alert but forgetful.
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The patient refused autopsy.
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The patient has no previous history of suicides.
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Patient has left white blood cells at another hospital.
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Patient’s medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.
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Patient had waffles for breakfast and anorexia for lunch.
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Both breasts are equal and reactive to light and accommodation.
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The lab test indicated abnormal lover function.
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Skin: somewhat pale but present.
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The pelvic exam will be done later on the floor.
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Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen and I agree.
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Large brown stool ambulating in the hall.
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Patient has two teenage children, but no other abnormalities.
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