Medical Record Quotes

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The following quotes were taken from actual medical records dictated by physicians. They appeared in a column written by Richard Lederer, Ph.D., for the Journal of Court Reporting.

* By the time he was admitted, his rapid heart had stopped, and he was feeling better.

*Patient has chest pain if she lies on her left side for over a year.

*The patient states there is a burning pain in his penis which goes to his feet.

*On the second day the knee was better and on the third day it had completely disappeared.

*She has had no rigors or shaking chills, but her husband states she was very hot in bed last night.

*The patient has been depressed ever since she began seeing me in
1983.

*I will be happy to go into her GI system; she seems ready and anxious.

*Patient was released to outpatient department without dressing. I have suggested that he loosen his pants before standing, and then, when he stands with the help of his wife, they should fall to the floor.

*The patient is tearful and crying constantly. She also appears to be depressed.

*Discharge status: Alive but without permission. The patient will need disposition, and therefore we will get Dr. Blank to dispose of him.

*Healthy appearing decrepit 69 year-old male, mentally alert but forgetful.

*The patient refused an autopsy.

*The patient has no past history of suicides.

*The patient expired on the floor uneventfully.

*Patient has left his white blood cells at another hospital.

*Patient was becoming more demented with urinary frequency.

*The patient's past medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.

*She slipped on the ice and apparently her legs went in separate directions in early December.

*The patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room.

*The patient left the hospital feeling much better except for her original complaints.




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