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:
The baby was delivered, the cord clamped and cut and handed to the pediatrician, who breathed and cried immediately.
Exam of genitalia reveals that he is circus sized.
The skin was moist and dry.
Rectal exam revealed a normal size thyroid.
She stated that she had been constipated for most of her life until 1989 when she got a divorce.
The patient was in his usual state of good health until his airplane ran out of gas and crashed.
I saw your patient today, who is still under our car for physical therapy.
The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week.
Bleeding started in the rectal area and continued all the way to Los Angeles.
She is numb from her toes down.
The patient had waffles for breakfast and anorexia for lunch.
Exam of genitalia was completely negative except for the right foot.
While in the emergency room, she was examined, X-rated and sent home.
The lab test indicated abnormal lover function.
The patient was to have a bowel resection. However he took a job as a stockbroker instead.
Occasional, constant, infrequent headaches.
Coming from Detroit, this man has no children.
Examination reveals a well-developed male lying in bed with his family in no distress.
Patient was alert and unresponsive.
When she fainted, her eyes rolled around the room.
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.
Both breasts are equal and reactive to light and accommodation.
The lab test indicated abnormal lover function.
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.
