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Comments On Patient Charts

Posted by cls On January - 13 - 2009

There were so many ways to misstate a health problem. The following are comments from doctors as recorded on patient charts.

  1. By the time he was admitted, his rapid heart stopped, and he was feeling better.
  2. Discharge status: Alive but without permission.
  3. Healthy appearing decrepit 69 year-old male, mentally alert but forgetful.
  4. I saw your patient today, who is still under our car for physical therapy.
  5. Occasional, constant, infrequent headaches.
  6. On the 2nd day the knee was better and on the 3rd day it disappeared completely.
  7. Patient had waffles for breakfast and anorexia for lunch.
  8. Patient has chest pain if she lies on her left side for over a year.
  9. Patient has left his white blood cells at another hospital.
  10. Patient has two teenage children but no other abnormalities.
  11. Patient was alert and unresponsive.
  12. Patient was released to outpatient department without dressing.
  13. Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen, and I agree.
  14. Patient’s past medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.
  15. She has had no rigors or shaking chills, but her husband states she was very hot in bed last night.
  16. She is numb from her toes down.
  17. She stated that she had been constipated for most of her life, until she got a divorce.
  18. Skin: Somewhat pale but present.
  19. The patient expired on the floor uneventfully.
  20. The patient has been depressed ever since she began seeing me in 1993.
  21. The patient has no past history of suicides.
  22. The patient refused an autopsy.
  23. The patient was in his usual state of good health until his airplane ran out of gas and crashed.
  24. The patient was to have a bowel resection. However, he took a job as a stockbroker instead.
  25. The patient will need disposition, and therefore we will get Dr. Blank to dispose of him.
  26. The skin was moist and dry.
  27. When she fainted, her eyes rolled around the room.
  28. While in the ER, she was examined, X-rated and sent home.

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