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The Importance Of Careful Medical Charting

Written by Wellness Club on May 15, 2008 – 3:07 pm -

As most readers know, careful and complete chart notes are very important in documenting the care of a patient. Sometimes though practitioners get a little harried or busy, and things don’t always read the way they were intended. Here are some examples of those bloopers, for your enjoyment:Actual Medical Chart Notes

1. Patient has two teenage children, but no other abnormalities.
2. Patient has chest pain if she lies on her left side for over a year.
3. On the second day, the knee was better, and then on the third day it disappeared.
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 last 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. She is numb from her toes down.
15. While in ER, she was examined, x-rated and sent home.
16. The skin was moist and dry.
17. Occasional, constant, infrequent headaches.
18. Patient was alert and unresponsive.
19. She stated that she had been constipated for most of her life until she got a divorce.
20. Rectal examination revealed a normal-size thyroid.
21. I saw your patient today, who is still under our car for physical therapy.
22. The lab test indicated abnormal lover function.
23. The patient was to have a bowel resection. However, he took a job as a stockbroker instead.
24. Skin: somewhat pale but present.
25. The pelvic exam will be done later on the floor.
26. Patient was seen in consultation by Dr. ____, who felt we should sit on the abdomen and I agree.
27. Large brown stool ambulating in the hall.
28. She has no rigors or shaking chills, but her husband states she was hot in bed last night.
29. Patient was found in bed with her power mower.

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