Published
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 had completely disappeared.
Father died in his 90's of female trouble in his prostate and kidneys.
Skin: Somewhat pale but present.
The pelvic examination will be done later on the floor.
Vomiting of unknown origin.
Admitted in error.
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.
Discharge status: Alive but without permission.
Dr. Blank is watching his prostate.
If he squeezes the back of his neck for 4 or 5 years it comes and goes.
this was a mistake i made when i was doing externship hrs @ a clinic for my Medical Assistant training...... the office was really busy that day with a staff consisting of Doctor , his wife(office manager!! yeah i know not fun enviornment), Medical assistant that worked there for 15+ YEARS.... and me!!giving them my very educational fee labor..... so plenty of people that day coming going both waiting rooms were to full capacity with patients in each of the 3 exam rooms and lab area the office manager always ordered me to do like 3 diff things at the same time!! so she was ordering me to make a chart for a new patient that had just walked in and at the same time she wanted me to give someone their appt... and couple of other things she was ordering me to to .... so i made the chart ... vitaled the patient put it in the chart holder to be seen ..... the doctor later on started yelling out asking where in the heck was this PT!!!! office manager screams well he left over an hour ago what is your problem!!! doc sez WHY IS HIS NAME ON THIS CHART!!! oopsies :) my bad i know ....
Some additional quotes made by physicians in actual medical records: Discharge status: alive but without permission.
The patient has been depressed ever since she began seeing me in 1983.
The patient refused an autopsy.
The patient has no past history of suicides.
Patient has left his white blood cells at another hospital.
Between you and me, we ought to be able to get this lady pregnant.
Since she can't get pregnant with her husband, I thought you would like to work her up.
She is numb from her toes down.
Occasional, constant, infrequent headaches.
Exam of genitalia reveals that he is circus sized.
Rectal exam revealed a normal size thyroid.
The patient was prepped and raped in the usual manner.
Both breasts are equal and reactive to light and accommodation
Ok i know this is old..but OMG if i ever see these on a chart, there is NO WAY that i will be able to keep a straight face when i see the doctor. You would think that a doctor would be able to get these things right???
getoverit, BSN, RN, EMT-P
432 Posts
today this one was written
"Referred to our service for evaluation of 3 day hx-n/v/d. patient seen at 10 am and stuffed with Dr. ____ at 1030."
another weird abbreviation. "bbs-gntb", when asked we were told "bilat breath sounds-good, not too bad"