Saturday, April 28, 2007

Actual Documentations Found in Patient Records


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 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.

While in ER, she was examined, x-rated and sent home.

Patient was alert and unresponsive.

She stated that she had been constipated for most of her life, until she got a divorce.

The patient was to have a bowel resection. However, he took a job as a stock broker instead.

Patient has two teenage children, but no other abnormalities.

From Nursing Guide Erika Lowndes(http://nursing.about.com/index.htm)

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