ACTUAL EXCERPTS FROM PATIENT RECORDS
Actual Documentations Found in Patient Records - Brought to you by Nursing Guide Erika Lowndes (
Health Careers)
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 disappeared.
The patient has been depressed since she began seeing me in 1993.
Discharge status: Alive but without my permission.
Healthy appearing decrepit 69-year-old male, mentally alert but forgetful.
The patient refused autopsy.
The patient has no previous history of suicides.
Patient has left white blood cells at another hospital.
Patient's medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.
Patient had waffles for breakfast and anorexia for lunch.
She is numb from her toes down.
While in ER, she was examined, X-rated and sent home.
The skin was moist and dry.
Occasional, constant infrequent headaches.
Patient was alert and unresponsive.
Rectal examination revealed a normal size thyroid.
She stated that she had been constipated for most of her life, until she got a divorce.
Both breasts are equal and reactive to light and accommodation.
Examination of genitalia reveals that he is circus sized.
The patient was to have a bowel resection. However, he took a job as a stock broker instead.
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.