Actual writings on hospital charts: 1. She has no rigors or shaking chills , but her husband states she was very hot in bed last night. 2. Patient has chest pain if she lies on her left side for over a year. 3. On the second day the knee was better, and on the third day it disappeared. 4. The patient is tearful and crying constantly. She also appears to be depressed. 5. The patient has been depressed since she began seeing me in 1993. 6. Discharge status: Alive but without my permission. 7. The patient refused autopsy. 8. The patient has no previous history of suicides. 9. Patient has left white blood cells at another hospital. 10. Patient had waffles for breakfast and anorexia for lunch. 11. She is numb from her toes down. 12. The skin was moist and dry. 13. Occasional, constant infrequent headaches. 14. Patient was alert and unresponsive. 15. I saw your patient today, who is still under our car for physical therapy. 16. Both вrеаsтs are equal and reactive to light and accommodation. 17. The lab test indicated abnormal lover function. 18. Skin: somewhat pale but present. 19. The pelvic exam will be done later on the floor. 20. Large brown stool ambulating in the hall. 21. Patient has two teenage children, but no other abnormalities.
Actual writings on hospital charts:
1. She has no rigors or shaking chills , but her husband states she was very hot in bed last night.
2. Patient has chest pain if she lies on her left side for over a year.
3. On the second day the knee was better, and on the third day it disappeared.
4. The patient is tearful and crying constantly. She also appears to be depressed.
5. The patient has been depressed since she began seeing me in 1993.
6. Discharge status: Alive but without my permission.
7. The patient refused autopsy.
8. The patient has no previous history of suicides.
9. Patient has left white blood cells at another hospital.
10. Patient had waffles for breakfast and anorexia for lunch.
11. She is numb from her toes down.
12. The skin was moist and dry.
13. Occasional, constant infrequent headaches.
14. Patient was alert and unresponsive.
15. I saw your patient today, who is still under our car for physical therapy.
16. Both вrеаsтs are equal and reactive to light and accommodation.
17. The lab test indicated abnormal lover function.
18. Skin: somewhat pale but present.
19. The pelvic exam will be done later on the floor.
20. Large brown stool ambulating in the hall.
21. Patient has two teenage children, but no other abnormalities.