July 27, 2012 – A Lighthearted Case for Electronic Medical Records

The last time I visited Dr. Lerner, my oncologist, he consulted my thick file, as usual.  Yet, as I answered his questions, I noticed he was doing something a little different: he was entering notes directly into a computer terminal. When I asked him about it, he confirmed what I suspected to be true: that his office is in the process of transitioning to an automated record-keeping system.

He didn’t sound 100% happy about it, but let it be known this is something “they” are insisting on.  Who “they” are wasn’t entirely clear: maybe our local hospitals, the insurance companies, the pharmaceutical companies, the State – or perhaps all of the above. He did grudgingly admit it will result in more accurate transmission of information – even though it means a big adjustment for him, his colleagues and their office staff. I imagine the transition period is especially trying.

Now, I don’t know how much of the information entered into the new system is narrative, and how much numeric.  Whatever the ratio, it should help solve one of the traditional problems with doctors’ record-keeping: poor handwriting.

I have no way of knowing whether the new procedures will cut down on the sort of mangling of the English language evident in the following examples, culled from actual medical charts. This item’s been circulating on the Internet for some time, but I still find it amusing. Hope it makes you smile, too:

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

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

3.  On the second day the knee was better, and on the third day it disappeared.

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

5.  The patient has been depressed since she began seeing me in 1993.

6.  Discharge status: Alive but without my permission.

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

8.  The patient refused autopsy.

9.  The patient has no previous history of suicides.

10. Patient has left white blood cells at another hospital.

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

12.  Patient had waffles for breakfast and anorexia for lunch.

13.  She is numb from her toes down.

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

15.  The skin was moist and dry.

16.  Occasional, constant infrequent headaches.

17.  Patient was alert and unresponsive.

18.  Rectal examination revealed a normal size thyroid.

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

20.  I saw your patient today, who is still under our car for physical therapy.

21.  Both breasts are equal and reactive to light and accommodation.

22.  Examination of genitalia reveals that he is circus sized.

23.  The lab test indicated abnormal lover function.

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

25.  Skin: somewhat pale but present.

26.  The pelvic exam will be done later on the floor.

27.  Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen and I agree.

28.  Large brown stool ambulating in the hall.

29.  Patient has two teenage children, but no other abnormalities.