Ah, the joys of (mis)communication! Consider, for example, these real-life chart notes written about hospital patients in the U.K. :
- 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.
- The patient is tearful and crying constantly. She also appears to be depressed.
- 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 female, mentally alert but forgetful.
- The patient refused autopsy
- Patient’s medical history has been remarkably insignificant with only a 40lb weight gain in the past 3 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.
- 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 car for physical therapy.
- Skin: somewhat pale but present.
- Patient has two teenage children, but no other abnormalities.
Q: Have you come across funny chart notes like these?