Thursday, August 12, 2010

Words you don't want to read in a chart

Usually medical charting follows a time-honored format: Situation (why they're there to see you) Background information, Assessment information, Recommendations (changes in medications, etc.) It's generally pretty dry stuff, but occasionally things jump at out me as I'm reading through the patient's previous visit notes.

(On a developmentally disabled client who lived in a group home:) "He was fired from work after he destroyed the mail box and ran naked through the streets."

(From a patient complaining of right-sided numbness that started three days earlier:) "I am worried that he has had a small stroke, and I told him he needs to see his PCP ASAP. Although, given his history of heroin abuse, I am also concerned that his condition may be due to peripheral nerve damage after laying on the floor for an extended period of time--essentially comatose."

(Concerning a woman who had a history of asking for early refills on her Xanax, claiming her purse was stolen, pills were lost, etc.:) "Ms. Histrionic seems to be making a full-time career out of requesting early fills on her meds and I told her in no uncertain terms that she needs to do a better job of keeping track of her belongings."

(On a gentleman who'd recently gotten out of jail and was required to seek mental health treatment as a condition of his parole:) "Legal history: Client was arrested at age 8 for possession of methamphetamine. He says he used to smoke it with his mother..."

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