Below are some excerpts from an unknown website. There are supposed to be actual transcriptions from medical records. Whilst most are funny, they do demonstrate the importance of being very careful of what you say and how you say it! What you write is there forever, and may be read out in a court of law.
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 suicides.
Patient has left white blood cells at another hospital.
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.
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.
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.
Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen and I agree.
Large brown stool ambulating in the hall.
Patient has two teenage children, but no other abnormalities
ps:malas sungguh nk wat assignment, cuti dh nk abes... huhu... aku sbg wakil dak2 bln 9 mengucapkan berjuta2 sori kepade Dati... aaaaaaaa
1 comment:
oit
buat la esaimen tu!
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