Authored by BlueAngel on
Wednesday, November 24, 2004
These particular chartings are very true to life. If you pick up an old hospital record or even a new one (chart), you would be truly amazed at the comments -- both humerous as well as the "? stupid ones".
A retired RN friend sent these remarks (she found in one of her internet sources) on to this "ole" retired RN (knowing that the remarks would be very appreciated). Hope you enjoy them also.
ACTUAL CHARTING ON HOSPITAL CHARTS
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 husband states 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 my 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.
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