I wandered upon this today. Another reason why everyone should pay attention during English class...
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.
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.
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.
While in the emergency room, she was examined, X-rated and sent home.
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.
On the second day the knee was better, and on the third day it disappeared.
The patient has been depressed since she began seeing me in 1993.
Discharge status: Alive but without my permission.
The patient refused autopsy.
The patient has no previous history of suicides.
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.
