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28 February 2012

Medical notes

We all know how important documentations are in our daily lives. Especially when it comes to our medical records, it is crucial that we need to be very accurate and clear. We sometimes moan about how much we spend time on writing rather than actually seeing patients. At the same time, we all understand how important these documentations are. We are all reminded many times by senior staff and medial record keeping team that "if they are not written, it is not been done" no matter how hard you work to save a person's life. However, just like in all other languages, the way we use words and phrases, can lead to second meaning. Here is a copy from "Confessions of a GP" 

These are apparently real extracts from medical notes. So here goes;

1. She has no rigours or chills, but her husband states she was very hot in bed last night.

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, but 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 permission

7. Healthy-appearling decrepit 69-year-old male, mentally alert but forgetful

8. The patient refused autopsy

9. The patient has no previous history of sucides

10. Patient has left white blood cells at another hospital

11. Patients'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. She is numb from her toes down

14. While in ER, she was examined, X-rated and sent home.

15. The skin was moist and dry.

16. Occasional, constant infrequent headaches.

17. Patient was alert and unresponsive.

18. Rectal examination revealed a normal-sized thyroid.

19. She stated that she had been constipated for most of her life, until she got a divorce.

20. I saw your patient today, who is still under our car for physical therapy.

21. Both breasts are equal and reactive to light and accommodation.

22. Examination of genitalia reveals that he is circus-sized.

23. The lab test indicated abnormal lover function.

24. The patient was to have a bowel resection. However, he took a job as a stockbroker in-stead.

25. Skin: somewhat pale but present.

26. The pelvic examination will be done later on the floor.

27. Patient was seen in consultation by Dr. Blank,, who felt we should sit on the abdomen and I agree.

28. Large brown stool ambulating in the hall.

29. Patient has two teenage children, but no other abnormalities.

30. The patient experienced sudden onset of severe shortness of breath at home while having sex, which gradually deteriorated in the emergency.

31. By the time he was admitted, his rapid heart had stopped, and he was feeling better.

32. Patient was released to out patient department without dressing.

33. She slipped on the ice and apparently her legs went in separate directions in early December.

34. The baby was delivered, the cord clamped and cut, and handed to paediatrician, who breathed and cried immediately.

35. When she fainted, her eyes rolled around the room.

These notes cracked me up every time I read them, so I have to share. These are direct copy from "Confessions of a GP" written by Dr. Benjamin Daniels.