Actual Writings on Hospital Charts

G-Rated

• On the second day the knee was better, and on the third day it disappeared.
• 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.
• Patient's medical history has been remarkably insignificant with only a 40-pound weight gain in the past three days.
• Patient had waffles for breakfast and anorexia for lunch.
• 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.
• 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.
• The patient was to have a bowel resection. However, he took a job as a stockbroker instead.
• Skin: somewhat pale but present.
• 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