Wednesday, December 24, 2008

Keeping the Record Straight

Just in case anyone still questions why a solid education in the English language is necessary, the following are actual notes from hospital charts. Thanks to my cousin who sent me these saying, "It's not just your students!"

1. The patient refused autopsy.
2. The patient has no previous history of suicides.
3. Patient has left white blood cells at another hospital.
4. She has no rigors or shaking chills, but her husbandstates she was very hot in bed last night.
5. Patient has chest pain if she lies on her left side for over a year.
6. On the second day the knee was better, and on the third day it disappeared.
7. The patient is tearful and crying constantly. She also appears to be depressed.
8. The patient has been depressed since she began seeing me in 1993.
9. Discharge status: Alive but without permission.
10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.
11. Patient had waffles for breakfast and anorexia for lunch.
12. She is numb from her toes down.
13. While in ER, she was examined, x-rated and sent home.
14. The skin was moist and dry.
15. Occasional, constant infrequent headaches.
16. Patient was alert and unresponsive.
17. Rectal examination revealed a normal size thyroid.18. She stated that she had been constipated for most of her life, until she got a divorce.
19. I saw your patient today, who is still under our car for physical therapy.
20. Both breasts are equal and reactive to light and accommodation.
21. Examination of genitalia reveals that he is circus sized.
22. The lab test indicated abnormal lover function.
23. Skin: somewhat pale but present.
24. The pelvic exam will be done later on the floor.
25. Patient has two teenage children, but no other abnormalities.


G6 said...

Sad, but oh so funny.......
In your next post kindly list the names of the doctors/hospitals so I know which institutions to avoid ;)

ProfK said...

If only it were limited to a few doctors and hospitals. I had an emergency apendectomy on a Shabbos. As I was lying on the operating table, not yet completely under the anesthetic, a nurse came in and asked "Does anyone know who this patient is?" You can't imagine my agitation--luckily the anesthetic took affect. But there is a post script to the story. When you first come out from under anesthetic there are some proscripted questions that they ask you to see if you are back to normal or not. The first question is "Do you know your name?" They couldn't understand why I was freaking out.

Anonymous said...

Not to ruin your day or anything but are you sure that they really took your appendix out?

Lion of Zion said...


i knew someone in high school who went in for an emergency apendectomy and they took out something else with it (i forget which organ)


having done hospital rounds, i can tell you that residents (i'm not a resident) have so much work to do that it is inevitable that charts will read this way. these examples are not (necessarily) indicative of poor education but rather being overworked (with some carelessness for good measure). besides, these are really funny, but most are perfectly understandable.

but anyway my craziest experience: i was once looking up something in a chart and i couldn't understand the flow of the resident's notes. then i realized she was talking on the phone as she typed, and every other sentence was actually a sentence from her conversation!

how about a movie.
patiet complains of sternal pain that subsides with rest.
and maybe with dinner too.
called 911 after having the pain for 2 hours.
it would be best if bill drives.
etc. . . .

Anonymous said...

Bottom line is the question remains, why indeed do schools force unwilling students to learn things like science and math, that most of them will have no use for, and some strongly resent being forced to study?Instead of biology and chemistry teach and stress important things like health/first aid.Instead of post alegbra math focus on car mechanics,basic home repairs and finance/economics.Instead of literture focus on how to spell and use a grammer correctly (the one thing I wished I would of been taught in high school.Instead they were too worried about Shakespeare and identifing what's a verb and what's a predicate).etc.

Anonymous said...

"Instead of literture focus on how to spell and use a grammer correctly (the one thing I wished I would of been taught in high school.Instead they were too worried about Shakespeare and identifing what's a verb and what's a predicate).etc."

What's a verb and what's a predicate is grammar.

Ideally, you'll do both Shakespeare and grammar. The bigger problem is that grammar is no longer taught to the same degree in elementary school, which puts the burden on high school to make the kids both fluent and cultured.

Ilana said...

I can't remember the last time I laughed so hard. I totally understand how these mistakes can happen when doctors are tired and overworked -- but the mistakes sure are funny to read.