Actual Sentences Found In Patients Hospital Charts

  1. 1. She has no rigors or shaking 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, and 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 past 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. Since she can't get pregnant with her husband, I thought you might like to work her up.
    15. She is numb from her toes down.
    16. While in ER, she was examined, X-rated and sent home.
    17. The skin was moist and dry.
    18. Occasional, constant, infrequent headaches.
    19. Patient was alert and unresponsive.
    20. Rectal examination revealed a normal size thyroid.
    21. She stated that she had been constipated for most of her life, until she got a divorce.
    22. I saw your patient today, who is still under our car for physical therapy.
    23. Both breasts are equal and reactive to light and accommodation.
    24. Examination of genitalia reveals that he is circus sized.
    25. The lab test indicated abnormal lover function.
    26. The patient was to have a bowel resection. However, he took a job as a stock broker instead.
    27. Skin: somewhat pale but present.
    28. The pelvic exam will be done later on the floor.
    29. Patient was seen in consultation by DR. Blank, who felt we should sit on the abdomen and I agree.
    30. Patient has two teenage children, but no other abnormalities

    :roll :roll
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  2. 34 Comments

  3. by   NurseDennie
    OMG!!!!!!!!!!!

    This just killed me. I laughed until I cried when I read the one about the rectal exam revealing a normal thyroid!!!

    Note to self: Make sure I am NEVER that doctor's patient!!!!

    Love

    Dennie
  4. by   fedupnurse
    I posted this on another thread but it's worth repeating: In my pt.'s H&P actually read the following:
    Pt has a history of alcolholism and a motor vehicle accident while in a coma.
    Moral of this story: Never, ever drink and drive while in a coma!
  5. by   zumalong
    In my years of teaching I have seen some notes (that don't make it to the charts--):
    Patient urineating just fine.
    I was just talking to her and she hauled off and started beating on me--she is crazy.
    Gave resident perrenial care.
    Resident incompetant X 3

    I could go on--but I must go to clinical and send some more new nurses into the world.
  6. by   Sleepyeyes
    Local hospital musta had a new transcriptionist. Neatly typed in Pt.'s H&P was, "Pt. has heparin C, in addition to other liver..."
  7. by   kimtab
    Thanks! I almost fell outta my chair!

    Kim
  8. by   auntie taz
    Thanks!! I did fall out of my chair!!!
  9. by   Rustyhammer
    My wife is sitting here wondering why I am LMAO!
    I saw one one day said something like Patient voice no complaint-large BM ambulating down hall.
    -R
  10. by   Jen911
    I wrote a triage note last night and gave it to our ER doc before realizing what I wrote... had to go crawl under the desk after I realized what I did... "Patient cut finger with knife after cutting cheese."
  11. by   Sleepyeyes
    Originally posted by Rustyhammer
    My wife is sitting here wondering why I am LMAO!
    I saw one one day said something like Patient voice no complaint-large BM ambulating down hall.
    -R
    "Large BM ambulating down hall" ???? --Is THAT what that was???!!
    :roll
  12. by   sunnygirl272
    Originally posted by Sleepyeyes


    "Large BM ambulating down hall" ???? --Is THAT what that was???!!
    :roll
    and i thought it was a new doctor!?!?!!?!:chuckle
  13. by   h2ogoddess
    I had a co-worker on 11-7 shift(need I say more),who worked LTC, after a long, tough night, she charted "Mr.XYZ,was up most of the shift, he is know asleep outback in the shed."
  14. by   Becka
    I once found this on a chart: "pt tol procedure well with O2 sats remaining in the high 80's but he died anyway"

    Becka

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Actual Sentences Found In Patients Hospital Charts