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 years 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.
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“When I told my doctor that I couldn’t afford an operation, he offered to touch up my X rays.”
Henny Youngman
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Who ever thought up the word “Mammogram”?
Every time I hear it, I think I’m supposed to put my breast in an envelope and send it to someone.
Jan King
