Adventures in Charting

This is from a handout that one of my nursing professors gave us. These were collected from actual patient medical records:

1. The baby was delivered, the cord clamped & cut & handed to the pediatrician, who breathed & cried immediately.
2. The skin was moist & dry.
3. Rectal exam revealed a normal size thyroid.
4. She stated that she had been constipated for most of her life until 1989 when she got a divorce.
5. Between you and me, we ought to be able to get this lady pregnant.
6. The patient was in his usual state of good health until his airplane ran out of gas & crashed.
7. I saw your patient today, who is still under our car for physical therapy.
8. The patient lives at home with his mother, father & pet turtle, who is presently enrolled in day care 3 times a week.
9. She is numb from the toes down.
10. While in the ER, she was examined, X-rated & sent home.
11. The patient was to have a bowel resection. However he took a job as a stockbroker instead.
12. Occasional, constant, infrequent headaches.
13. Patient was alert & unresponsive.
14. When she fainted, her eyes rolled around the room.
15. The patient had waffles for breakfast & anorexia for lunch.
16. We will follow her eyes & nose with a foley catheter.
17. By the time he was admitted his rapid heart had stopped & he was feeling better.
18. Patient has chest pain if she lies on her left side for over a year.
19. On the 2nd day the knee was better & on the 3rd day it had completely disappeared.
20. Patient has been depressed ever since she began seeing me in 1983.
21. Patient is tearful & crying constantly; she also appears to be depressed.
22. Discharge status: alive but without permission.
23. Healthy-appearing decrepit 69 year old male, mentally alert but forgetful.
24. The patient refused an autopsy.
25. The patient expired on the floor uneventfully.
26. The patient has left his white blood cells at another hospital.
27. Patient’s past medical history has been remarkably insignificant, with only a 40lb weight gain in the last 3 days.
28. She slipped on the ice & apparently her legs went in different directions in early December.

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