Actual Writings On Hospital Charts

Actual Writings On Hospital Charts

The following quotes are taken from actual patient hospital charts, mainly in the United States.  They have been reproduced before, but they never get old.  Enjoy.

“The patient has been depressed ever since she began seeing me in 1993.”

“Rectal exam revealed a normal size thyroid.”

“Bleeding started in the rectal area and continued all the way to Los Angeles.”

“She has no rigors or chills but her husband says she was very hot in bed last night.”

“Patient has two teenage children but no other abnormalities.”

“Patient had waffles for breakfast and anorexia for lunch.”

“The patient has no past history of suicides.”

“She can’t get pregnant with her husband, so I will work her up.”

“Healthy appearing decrepit 69 year-old male, mentally alert but forgetful.”

“A midsystolic ejaculation murmur heard over the mitral area.”

“Both breasts are equal and reactive to light and accommodation.”

“Occasional, constant, infrequent headaches.”

“The baby was delivered, the cord clamped and cut, and handed to the pediatrician, who breathed and cried immediately.”

“Between you and me, we ought to be able to get this woman pregnant.”

“The patient refused autopsy.”

“The lab test indicated abnormal lover function.”

“The pelvic exam will be done later on the floor.”

“Skin: somewhat pale but present.”

“Large brown stool ambulating in the hall.”

“Exam of genitalia was completely negative except for the right foot.”

“Examination reveals a well-developed male lying in bed with his family in no distress.”

“Patient’s past medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.”

“She stated that she had been constipated for most of her life, until she got a divorce.”

“While in the ER, she was examined, X-rated and sent home.”

“When she fainted, her eyes rolled around the room.”

“Patient has chest pain if she lies on her left side for over a year.”

“Exam of genitalia reveals that he is circus sized.”

“Discharge status: Alive but without permission.”

 The best one I ever actually saw was at the S. Nassau Hospital outpatient mental health clinic where someone had transcribed a psychiatrist's order as: "patient to have an enema of the brain" when what he ordered was an MRI of the brain.