Patient Charts

Email that I just got - seemed topical enough


Reportedly actual writings from 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 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. (OUCH!)

  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.

The Snopes article doesn’t mention another reason why you end up with such howlers - that these notes are being dictated. I’m more comfortable than I used to be with dictation but it’s still not a natural form of communication for me and it’s easy to ramble or lose your train of thought. Unless you back up the transcription equipment to make sure you’ve said stuff that makes sense (and no one does that because it’s too time-consuming), I suspect that more dictated notes contain odd phrases and non sequiturs than DON’T.

Still, these things make me laugh every time I read them.


These are similar to what we see/hear in the software development world. One prevelant example a few years back was feedback received from Software Installation Customer Support.

Customers were calling into the support center to complain that they could not find the “anykey” on the keyboard when prompted by the software installer to press “Any Key”.