KB Posted August 22, 2008 Report Share Posted August 22, 2008 The following quotes from actual medical records dictated by physicians appeared in a column written by Richard Lederer, PhD, 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. * On the second day the knee was better and on the third day it had completely disappeared. * She has had no rigours 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 female, 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 oedema at home while having sex which gradually deteriorated in the emergency room. * The patient left the hospital feeling much better except for her original complaint. Ken The following little official bit is for Pugwash and Cornerstone. [source: ICD Coding Newsletter http://www.health.vic.gov.au/hdss/archive/...et/nsl_0497.doc] Link to comment Share on other sites More sharing options...
sssurfer Posted August 22, 2008 Report Share Posted August 22, 2008 Great! I love them! Anyway, those are better -- and they write better -- than most physicians in my country. Just, the one on suicides is absolutely true. Actually, 90% of suicides don't work -- i.e., 90% of suicides really do not want to put an end to their life. Link to comment Share on other sites More sharing options...
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