3.26.2010

What NOT to Chart

The following quotes were taken from actual medical records:
*By the time he was admitted, his rapid heart had stopped and he was feeling better.
*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 had completely disappeared.
*The patient has been depressed ever since she began seeing me in 1983.
*Patient was released to outpatient department without dressing.
*The patient is tearful and crying constantly. She also appears to be depressed.
*The patient will need disposition, and therefore we will get Dr. _____ to dispose of him.
*Healthy-appearing, decrepit 69-year-old male, mentally alert but forgetful.
*The patient refused an autopsy.
*The patient has no past history of suicides.
*The patient expired on the floor uneventfully.
*Patient has left his white blood cells at another hospital.
*She slipped on the ice and apparently her legs went in separate directions in early December.
*The patient left the hospital feeling much better except for her original complaints.
*While in the ER, she was examined, X-rated, and sent home.
*Patient was alert and unresponsive.
*Complains of feeling numb from her toes down.
*When she fainted, her eyes rolled around the room.
*Rectal examination revealed a normal-sized thyroid.
*Patient had waffles for breakfast and anorexia for lunch.
*Patient stated that she had been constipated for most of her life until 1989, when she got a divorce.
*Bleeding started in the rectal area and continued all the way to Los Angeles.
*The patient was to have a bowel resection. However, he took a job as a stockbroker instead.
*Fleets enema given with stool hard as pine knots.
*Patient complains of indigestion since last night when he ate a stake.
*Patient passed flatus...two short, one long.
*Patient was seen in consultation by the physician, who felt we should sit tight on the abdomen, and I agreed.
*Examination of genitalia reveals that he is circus-sized.
*Indwelling urinary catheter draining large amount of urine the color of American beer.
*MD at bedside attempted to urinate. Unsuccessful. [Intubation was unsuccessful.]
*Patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week.
*Patient was in his usual state of good health until his airplane ran out of fuel and crashed.
*Examination reveals a well-developed male lying in bed with his family in no distress.
*Skin was moist and dry.
*Both breasts are equal and reactive to light and accommodation.
*The baby was delivered: the cord, clamped and cut and handed to the pediatrician who breathed and cried immediately.
*Skin: somewhat pale, but present.
*I saw your patient today, who is still under our car for physical therapy.
*Because she can't get pregnant with her husband, I thought you'd like to work her up.
*The tests indicated abnormal lover function.
*If the squeezes the back of his neck for 4 or 5 years, it comes and goes.
*Discharge status: alive, but without permission.
*Gave nurse 2 Percocet per patient request.

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