From the Wonderful World of Medicine:
At one time or another, every health care professional has probably charted a note or two that didn’t come out quite right. These bloopers were collected from medical records across the US.
Cardiac:
Patient has chest pains if she lies on her left side for over a year.
By the time she was admitted to the hospital, her rapid heart had stopped and she was feeling much better.
Musculoskeletal:
On the second day, the knee was better, and on the third day, it had completely disappeared.
While in the emergency department, she was examined, x-rated, and sent home.
Gastrointestinal:
She stated that she had been constipated for most of her life until 1989 when she got a divorce.
Bleeding started in the rectal area and continued all the way to Los Angeles.
The patient was to have a bowel resection. However, he took a job as a stockbroker instead.
Patient complains of indigestion since last night when he ate a stake.
Miscellaneous:
Examination reveals a well-developed male lying in bed with his family in no distress.
Skin somewhat pale, but present.
The baby was delivered, the cord clamped and cut, and handed to the pediatrician who breathed and cried immediately.
I saw your patient today who is under our car for physical therapy.
Discharge status: alive, but without permission.