Charts

My summer work involves helping an orthopedic surgeon with some chart research. Here are couple of things that I thought were funny.

"patient appears to be significantly older than she claims"

I love how every patient seems to be described as pleasant. For instance, "Jane Smith is a pleasant young lady who presents to my service with..."

Referencing a 50+ year old: "The patient is here with her parents."

On a surgical note there always has to be a diagnosis. So commonly you would see something like "Diagnosis: left distal comminuted fracture of the radius." But because you need a 'diagnosis' for every procedure, when someone is just having surgery to remove plates and screws the diagnosis reads "Retained Hardware." As if some patients' hardware magically disappears when they no longer need it, while others have to come back for surgical removal.

For some reason it seems that doctors need to go over the top in thanking referring doctors. Many read like this, "Dr. Smith kindly/graciously/generously refered patient X to me to treat her..."