У меня вчера был класс по charting, ну вроде как нас учили правильно записывать наблюдения за пациентами и отчеты о проведенных процедурах. На самом деле это довольно важная составляющая работы, потому что, как говорится, если не записал, то, значит, и не сделал. В Канаде, как и везде, пациентов гораздо больше, чем медсестер и медбратьев, поэтому в спешке люди "чартят" зачастую такое! Ну просто перлы! Профессорша насобирала стоящие экземпляры из собственной практики и практик своих коллег. Кое-что так себе, вполне заурядные очепятки, но есть настоящие шедевры. Наиболее мне полюбившееся я выделила красным:
So, these are actual entries made in hospital charts:
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. Несговорчивый зараза! :)
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. Долгий путь к истине :)))))
19. She stated that she had been constipated for most of her life, until she got a divorce. Хорошее дело браком не назовут :)
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. Это мое любимое!
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 stockbroker instead.
25. Skin: somewhat pale but present.
26. The pelvic exam will be done later on the floor. Наверное, автор перла имел ввиду unit, но тут довольно часто в значении "отделение" используется 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. Как говорится, не пытайтесь это представить! :)
29. Patient has two teenage children but no other abnormalities.
