I used to work in Health Records and I have seen some very silly things; these are not them. I am taking this from an email my cousin sent me. VERY fun stuff!
"Actual sentences found in hospital patient charts"
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 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 male, mentally alert but forgetful.
The patient refused autopsy.
The patient has no previous history of suicide.
Patient has left white blood cells at another hospital.
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.
Between you and me, we ought to be able to get this lady pregnant.
Since she can't get pregnant with her husband, I thought you might like to work her up.
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.
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 car for physical therapy.
Both breasts are equal and reactive to light and accommodation.
Examination of genitalia reveals that he is circus sized.
The lab test indicated abnormal lover function.
The patient was to have a bowel resection. However, he took a job as a stock broker instead.
Skin: somewhat pale but present.
The pelvic exam will be done later on the floor.
Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen and I agree.
Patient has two teenage children, but no other abnormalities.