A gramatical overview of medical records: The Write Stuff

Corey D. Fox, Ph.D.

The following quotes were lifted verbatim fromt he medical records of a general hospital in a large metropolitan area.

• Patient suffers from headache while menstruating on the top of her head.
• There is a pressure bandage on the hip which is markedly swollen and tender.
• Patient is a newborn infant delivered over an intact perineum which cried spontaneously.
• Patient experiences difficulty swalloing tires easily.
• Patient had bronchoscopy today. Exam showed normal bowel to 25 cm.
• History: patient was shot in head with .32 caliber rifle. Chief Complaint: headache.
• Patient has difficulty walking on Digitalis.
• Patient had a D&C a year ago and all her eyebrows came off.
• Patient referred to hospital for repair of hernia by a social service worker.
• Patient sent to hospital for erosion of the cervix by a local medical doctor.
• Dictated: Patient had a Pap smear today. Transcribed: Patient had a Pabst Beer today.
• This was a nonsterile delivery by the nurse in the bed of a five pound male infant.
• Patient was struck by an auto while she was walking across the street at approximately 45 mph.
• Patient complains of worsening acne and itching rash as well as nasal congestion of his trunk.
• Patient referred to hospital by provate physician with green stools.
• This 54 year old female is complaining of abdominal cramps with BM's on the one hand and constipation on the other.
• This mother of a 2 year old desires a circumcision.
• Patinet was married twice, but denies any other serious illness.
• Patient's wife hit him over the head with and ironing board which now has six stitches on it.
• Patient is seperated from his wife, and is also allergic to Penicillin.
• Patient has no children and she doesn't smoke or drink either.
• [male patient]Pelvic exam: deferred.
• Rx: Mycostian vaginal supposiitories, #24. Sig: Insert daily until exhausted.

© 1997 snipe_hunter@hotmail.com

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