Andr-Tech uk666 Posted September 12, 2020 Andr-Tech Share #1 Posted September 12, 2020 funniest Medical Notes we know how important it is that our documentation is clear, succinct, and accurate. Apparently, these folks didn't get the memo. All of the names have been omitted to protect the innocent and not-so-innocent! These notes taken from Hospital patient record: Since she can't get pregnant with her husband, I thought you might like to work her up. She has no rigors or shaking chills, but her husband states she was very hot in bed last night. 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 2010. Discharge status: Alive but without my permission. Healthy appearing decrepit 69-year-old male, mentally alert but forgetful. The patient refused autopsy. The patient left the hospital feeling much better except for her original complaints. The patient has no previous history of suicides. Patient has left white blood cells at another hospital. The patient is tearful and crying constantly. She also appears to be depressed. 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 went 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. I saw your patient today, who is still under our care for physical therapy. Examination of genitalia reveals that he is circus sized. The lab test indicated abnormal lover junction. The patient was to have a bowel resection. However, he took a job as a stockbroker instead. Skin: somewhat pale but present. The pelvic exam will be done later on the floor. Patient has two teenage children but no other abnormalities. She slipped on the ice and apparently her legs went in separate directions in early December. 1 1 Link to comment
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