CHART DOCUMENTATION BLOOPERS FROM ACTUAL FILES
Patient experiences difficulty swallowing tires easily.
Patient was shot in the head with a .32 caliber rifle. Chief complaint: headache.
There was a nonsterile delivery by the nurse in a bed of a five-pound infant male.
Patient was referred to the hospital by a physician with green stools.
Patient was married twice but denies any other serious illness.
Patient separated from his wife and he's also allergic to penicillin.
Baby delivered, cord clamped and cut, handed to the pediatrician,
who breathed and cried immediately.
The skin was moist and dry.
The patient was to have a bowel resection, however, he took a job as a stock broker instead.
Pt is divorced from her ex-husband.
Pt had a partial hysterectomy and is now completely blind.
Urinalysis revealed moderate blood and trace urine.
Patient voids around the clock every two hours.
After the baby's head was removed, the remainder was delivered easily.
The patient is 72 years old. His mother is also elderly.
The patient is a 62 year old woman who was at a
flea market when she developed severe itching.
The patient had waffles for breakfast and anorexia for lunch.
She stated that she had been constipated for most of her life
until 1970 when she got a divorce.
The patient was in his usual state of good health until his airplane
ran out of gas and crashed.
Patient lives with his parents and pet turtle, who is presently
enrolled in day care three times a week.
Both breasts are equal and reactive to light.
She is numb from her toes down.
Bleeding started in the rectal area and continued all the way to Los Angeles.
Fetus is a male, no other gross abnormalities noted.
When she fainted, her eyes rolled around the room.
The patient is tearful and crying constantly and appears to be depressed.
The patient refused an autopsy.
The patient has no past history of suicide.
Discharge status: The patient will need disposition, and therefore
we will get Dr Lee to dispose of him.
Patient was becoming more demented with urinary frequency.
The patient expired on the floor uneventfully.
She slipped on the ice and apparently her legs went in separate
directions in early December.
Patient states he is in good health except for his illness.
On second day the knee was better and by the third it had completely disappeared.
The patient was seen in consultation by Dr Lee who feels we should sit on the abdomen.
Patient has two teenage children but no other abnormalities.
Patient was treated with oral suppositories.
Dr at beside attempting to urinate.
Patient alert but unresponsive.
By the time he was admitted, his rapid heart had stopped and he was feeling better.
Patient has chest pain if she lies on her left side for over a year.
The patient has been depressed ever since she began seeing me in 1985.
Patient released to outpatient dept without dressing.
Discharge status: Alive but without permission.
Healthy appearing, decrepit 72 yr old male.
Mentally alert, but forgetful.
Patient left his white blood cells at another hospital.
While at the hospital, she was examined, x-rated, and sent home.
Has occasional, constant, infrequent headaches.
She is numb fromher toes down.
Past medical history insignificant except for a 40 pound weigh gain in 3 days.
Experienced mood swings because she suffered from PBS.
Since the patient stopped smoking, his smell is beginning to return.
She is quite hard of hearing, as a matter of fact, she can't hear at all out of her left eye.
Sinuses run in the family.
The patient was bitten by a bat as he walked down the street on his thumb.
He was advised to force fluids through his interpreter.
Patient vehemently denies any auditory, tactile, or old factory hallucinations.
Pt continues to be confused. Oriented to person, place, and time.
Patient is on IV D5 1/2NS with Kay Ciel 20 meq/L.
The patient was BEAN BAGGED on 100% oxygen.
A full examination will be completed with the patient ON THE FLOOR.
Pt. reports relief from rectal exam per MD.
He is clearly psychotic this morning. He states he has a frog in his throat.
16 Fr foley inserted into pt's L nare.
Skin: Somewhat pale but present.
Vomiting of unknown origin.
Pt admitted in error.
Patient had a large brown stool ambulating in the hall.
Pt having small amount of pain after the baloney surgery.