30 Actual Sentences Found In Patients Hospital Charts

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I recently saw this post on a friend’s Facebook timeline, and was compelled to write a response to it. The thing is, most of these chart notes ARE funny, but some are taken out of context. In addition, the language used in several of the notes are completely appropriate when spoken within the medical world, so I clarified those notes in a comment which I posted. Here is the original list of chart comments, followed by my clarifying remarks.

http://www.tickld.com/x/jaw/30-actual-sentences-found-in-patients-hospital-charts

1. She has no rigors or shaking chills, but her husband states she was very hot in bed last night.
2. Examination of genitalia reveals that he is circus sized.
3. Since she can’t get pregnant with her husband, I thought you might like to work her up.
4. The patient is tearful and crying constantly. She also appears to be depressed.
5. The patient has been depressed since she began seeing me in 1993.
6. Discharge status: Alive but without my permission.
7. Healthy appearing decrepit 69 year-old male, mentally alert but forgetful.
8. The patient refused autopsy.
9. The patient has no previous history of suicides.
10. Patient has left white blood cells at another hospital.
11. Patient’s medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.
12. Patient had waffles for breakfast and anorexia for lunch.
13. Between you and me, we ought to be able to get this lady pregnant.
14. On the second day the knee was better, and on the third day it disappeared.
15. She is numb from her toes down.
16. While in ER, she was examined, X-rated and sent home.
17. The skin was moist and dry.
18. Occasional, constant, infrequent headaches.
19. Patient was alert and unresponsive.
20. Rectal examination revealed a normal size thyroid.
21. She stated that she had been constipated for most of her life, until she got a divorce.
22. I saw your patient today, who is still under our car for physical therapy.
23. Both breasts are equal and reactive to light and accommodation.
24. Patient has chest pain if she lies on her left side for over a year.
25. The lab test indicated abnormal lover function.
26. The patient was to have a bowel resection. However, he took a job as a stock broker instead.
27. Skin: somewhat pale but present.
28. The pelvic exam will be done later on the floor.
29. Patient was seen in consultation by DR. Blank, who felt we should sit on the abdomen and I agree.
30. Patient has two teenage children, but no other abnormalities.

As a physician, I know that some of these chart notes actually make perfect sense to those who work in the medical field and who are on the hospital wards.

For example, “Since she can’t get pregnant with her husband, I thought you might like to work her up.” refers to a physician referring a patient to a fertility specialist who would be able to “work up” a patients to see what the issue might be with respect to difficulty getting pregnant.

Here’s another one: “The patient is tearful and crying constantly. She also appears to be depressed.” Crying “constantly” does not automatically infer that someone is depressed. Ostensibly the patient is distressed over something, but the clinical diagnosis of depression has a set of criteria which must be met on evaluation of the patient.

“The patient has been depressed since she began seeing me in 1993.” Really, just stupid. This patient had depression beginning at the very latest in 1993, and this clinician had begun seeing the patient at that time. So snicker all you want, but the clinician’s presence in the patient’s life is NOT the causative factor in her depression.

“The patient was to have a bowel resection. However, he took a job as a stock broker instead.” If I could count the number of times a patient was advised to have a surgical procedure, only to evade medical advice, I’d be a millionaire by now.

“The pelvic exam will be done later on the floor.” The “floor” refers to a hospital ward. This patient was most likely evaluated in the emergency room, so the plan was to do a full work-up, including a pelvic exam, once the patient was transferred to a regular bed in the appropriate ward or section of the hospital.

“Patient was seen in consultation by DR. Blank, who felt we should sit on the abdomen and I agree.” The phrase, “sit on the abdomen” means that the clinicians who were evaluating the patient had decided to hold off on any interventions with respect to the abdomen, most likely because they were confident that there was no imminent danger, and no need for surgical intervention.

The remaining chart notes ARE funny, and I could see why lay people find them amusing.
Hope this clears up some of the confusion regarding some of the notes which were perfectly sound within the medical world.

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