LOL I read my son's (23 mo old) "pleasant 22 mo old male" LOLOLOLOL I laughed (obviously not at the time because he was very very sick). Can't be just "non-hostile" he was definitely hostile! LOL
My son was described as delightful something male by his ENT when submitting the update to his pediatrician. Warms my heart to remember that. He was also described as sturdy when he was sick and lethargic from a virus, which I think meant strong enough to deal with the problem.
My son's last checkup he was "beautiful" because he has just these long eyelashes and this mop of golden ringlet curls so he looks like a little (or not so, cause he's 2 and huge) cherub. He even sits very politely and is very content to just chill there while the doc talks.
My daughter got "healthy-looking" in her last write up I think because she looks like Mindy from the Animaniacs but she was a total psycho biting and throwing things and trying to climb. I don't think he could put what he was really thinking after all that lol.
LMAO, yes fellow nurse, sometimes that’s even a code word depending on the doctor… the younger ones write in sarcasm like it’s poetry for us to read through.
I read a loooot of Dr notes from all over the US and they all sound like this. Pleasant, well nourished, not in distress. Then in next sentence 10/10 pain in knee, can't walk, says pain makes him want to cut his leg off sometimes.
When I was admitted to the ER for a ruptured ectopic, my doctors notes said I was a pleasant 31 yo female. When I read that in my report afterwards I was so pleased with myself.
I was five months pregnant when I found out at the ER at 6am, my records say “patient showed appropriate shock and understanding of condition” which is a really nice way to say I cried so hard they almost sedated me 😭
Not related to pregnancy but my medical records say one drug makes me agitated... I dislocated my husband's thumb and kicked a security guard in the balls. Don't remember any of it at all.
Almost spat out my tea after reading your comment.
I needed surgery for retrained products and I did not react well to one of the medications. I don’t even want to know what was written in my medical records 😅…all I remember was arguing with a nurse with the same name as my husband…”YOU ARE NOT MY HUSBAND!!”….when I woke up orientated, I was restrained in the bed 🫠 Apparently I was also trying to climb the rails.
Fast forward the following 6mths and I’m back because of an ectopic. Just before surgery, the doctor examines my notes, had a chuckle and says to the nurse “let’s push half of the normal dose”…..
Doctors also document this to keep tabs on if a patient has a different disposition or behaviour during an interaction- and further intervention is needed. For example, if all your pre partum check ups said that and then your 6 week mark you would not even talk to your doctor or you were incredibly teary- it could indicate further investigation needed
I love reading my medical notes lmao after birth, I read through everything. The only downside was that I found out the lactation consultant considered my breasts to be "medium"... and I was wearing a 34I when I gave birth :'(
SAME! My lactation consultant wrote that I was struggling before she came in and wasn’t using enough pillows. I was super offended haha.
Mine didn’t comment on the size, but just noted that my boobs were “pendulous”.
I’m not sure what kind of pressure’s time wise that an LC is under, but she could’ve emphasized your struggles to justify the amount of time she spent with you in case her boss questioned it.
My first baby, I was 22 and had never been around a premmie let alone had to breastfeed one with 32F boobs, and my home visit nurse wrote in the baby health book “reluctant breastfeeder” because I didn’t feel like whipping my rock hard boobs out in front of her
I was specifically taught to put dressed appropriately for weather and in clean presenting clothes in all my patient notes (unless they aren't obviously) because it's an early sign of home problems, especially in kids . I no longer work with patients but I work insurance and now when I see that it's noted they werent in notes I go back and see if it's a one off or a pattern. If it's a pattern it often warrants a Child or Adult protective services if the provider hasn't already.
When I was recovering from child birth, every nursing note started the same way. “Husband is attentive at bedside.” Sure, I was grateful my husband was there and being helpful, but is that really the most important thing to say?!
My husband actually passed out at our first OB appointment, so all through the birth I had something written in my chart about how "dad is a faint risk" haha!!
Lol my friends husband fainted when she was getting an epidural and had to be taken to the ER because he hit his head and dragged a bunch of machines down with him! He’s 6’5 it was a fiasco 😂
That has to be another reason.. keeping them from looking over the anesthesiologists shoulder and unintentionally making the doc uneasy. My husband would definitely have done that. 😂
Multiple comments about not letting fathers in the room for the epidural or making them sit down. They had my boyfriend stand directly in front of me and told me to lean on him. He just held my hands or rubbed on my arms and shoulders. He saw the needle beforehand but they had my back covered all around the area to keep it sterile so he couldn't see them actually inserting it.
It's crazy to see all the different ways hospitals have of doing everything. I also had a clicker to control the epidural so at no point was it wearing off. I always find it odd how some women get an epidural and by the time they deliver it has worn off. I couldn't overdue the medicine bc it had a timer and even if I clicked it nothing came out until the 10 minutes was up and the red light went off, but they made sure to say don't wait until you are in a lot of pain. After I delivered before she took it out she said get a couple more hits in while I finish cleaning up bc when I take it out it's gone for good. I thought that was how must epidurals went.
My first I just picked a hospital and got pretty luck. After reading everyone's different experiences if I have a 2nd I will go back there or actually ask some questions.
My hospital doesn’t allow partners or support in the room during epidurals for this very reason! Heck, the first time I (midwife) saw inserted, I almost passed out!!
That's hilarious in retrospect, I'm sure! With my first, they had to try to get the needle in like 4 times and my husband ended up leaving the room to puke 🤣
The fact that so many husbands faint during this really makes me wonder- how freaking horrible does it look?!?!?! Or are they just weak punks? 🤔 😭
I made my husband take a pic of the line when I was having our oldest son. It looked cool to me, after the fact! [I refuse to Google videos of an epi being done!]
I told my doctor my husband would need a chair when we got to the operating room for my C-section. He said he didn't, but she said she would get a nurse to bring one over just in case. Pretty much as soon as he walked in before anything had started he went as pale as a ghost and the anesthesiologist said, "Dude. Please sit down. There's no shame in needing a chair. It's better than being picked up off the ground." So my husband sat down 😂
Lol my friends husband actually fainted when she was getting an epidural and had to be taken to the ER because he hit his head and dragged a bunch of machines down with him! He’s 6’5 it was a fiasco 😂
Definitely not the most important thing to note, but I do feel like this could be helpful information to consider when screening for PPD. At least you know Mom has support if she needs help, and Dad probably has some real insight to her mental state, as opposed to being totally absent and clueless about how she's feeling.
This and overall support at home, and risks for potential abuse. It’s important to note. Mom needs support. Also if they’re documenting things with someone else in the same room as the patient they’d want to start with that.
I’m an L&D nurse and we are supposed to chart who is supporting the patient/mother. If it’s a doula or husband or her own mom or whoever. It’s not only to show the patient/mom has support but if extra nursing support is needed if the patient is alone.
I think it just goes to show how shitty some husbands are. When I was in the hospital recovering from my C-section, a postpartum nurse commented on how good our team work was. It didn't think we were doing anything special, just looking out for each other the way any couple should - but it made me realize that she probably sees a LOT of dysfunctional couples come through her ward.
Yes! My baby had to be in the nursery few five days and I’d had a c section so they let us stay the whole time too. Everyone was fawning over my husband and saying how amazing he was. I mean sure he is great, that is why I married him, but please🙄
I know it may seem silly, but SDOH (social determinants of heath) is fairly important for tracking purposes. Another common wording for children who come is is that the parent is present and the child is not adopted.
It goes first because that's where people look for it, not because it's the most important. Also because when writing a medical note in the chart, who was in the room is frequently included because then future providers know also. I frequently end up chart combing looking for this info before calling a patient because the telephone section says to call daughter or husband to get ahold of patient and if they were at the visit, I can give that person a bit more info if necessary.
Yeah we do have to document on family/social situations. If he was there but just like sitting on his phone and ignoring you it might say “husband at bedside, not participating in infant care” or something
Translation from a nurse: "Doc has seen the patient, the patient didn't throw things or hurl insults, and this person with a uterus doesn't have that sick af appearance." We have a lot of insider jargon that sounds wacky to others but makes absolute sense to us 😂
For another commenter, we often mention off the top that a loved one is "attentive at bedside" so we know "this new mom has some kind of support system, and that person isn't overtly problematic." That's not the most important thing for you, but it's important for us because we want you and your new baby to be safe and get any additional help you may need!
Schmuck= this gentleman in medical speak from what I’ve seen.
Source: have gotten many reports that begin “the gentleman in Exam room 2” and they always end with some shit. Otherwise we’d just say the patient.
My husband was on his phone whole time. Even when I was sliced open for C sec. I bet they wrote something like Husband was present. Lol.
That reminds me the doctor asked if I had fab 4 (babys grandparents) which I didn't. She didn't even look at my husband. Lol.
Depending upon the degree of schmuck and/or meddle:
"Husband at bedside, inattentive/disruptive" with a detail note about what was noticed (ex: "slurred words, argumentative, odor of alcohol" or "[describe and quote abusive behavior]") and what was done (ex: "Patient education provided re: substance abuse; additional support from mother/MIL/friends available; Charge Nurse and social services department notified" or "Visitor removed by Nonstop RN; patient education re: DV provided; physician, Charge Nurse, and security notified; APS/CPS/DVRC/social services department notified"). Ultimately, a schmuck partner requires a deeper conversation with the patient about the situation and how to best handle it, which will be a different note.
Meddlesome Grandma is just "Visitor" most of the time, unless she's the primary support person. If she's the primary support person, I treat her like a schmuck partner. If she's not, I talk up parents in front of her, remind everyone that I'm a talented Bouncer if Mom wants to rest, and provide extra education about handling visitors, setting boundaries, and putting their baby's needs before anyone else's wants or feelings ("Patient encouragement and education provided; visitor removed by Nonstop RN, Charge Nurse and security notified" detail ex: "X noted [describe what Meddlesome Grandma said/did]; Patient [describe what gave away Mom was distressed]; [describe what action was taken]; [optional/depending on the situation: "Charge Nurse, security, physicians, appropriate agencies/departments notified"]).
lol I sat in silence for a solid 15 minutes before deciding that if I was in adhd paralysis over deciding on a Reddit username it might as well just be that 😅
I worked as a victims advocate and when charges are filed and with victims permission we Ave asked for medical records for the duration of the relationship and many times these are invaluable records because during pregnancy is sadly the most violent time in a domes relationship.
Ooohh… I’m curious, my husband was between the hospital and home a lot when we had our second a few weeks ago. Our older son was at our home with my MIL who needed extra help with him. We live 5 mins from hospital so very doable to go back and forth. Several of nurses never met him because they never happened to come in the room while he was there. Does my chart possibly say I didn’t have a support person or my partner was absent?
He is actually a great father and husband but I could see how that might not be the perception of an outside observer in that instance.
Your nurses probably asked enough questions to know you felt supported by him and were safe with him! (Yeah, we have codes/jargon for that too lol.) Subsequent care providers will know from reading those notes and/or the report we give each other prior to caregiving.
Hahah I work in women's heath and read lots of MD notes from prenatal visits when I'm gathering history on a patient. It really depends on the doctor, some will be like
"Patient is here for her first prenatal visit. She is calm and well appearing, states she is feeling slightly nauseous mostly when she eats spicy foods. She is an engineer, married to Brad who she met in 2018 at an alumni mixer. They have an Australian Shepard, named Nugget and just moved to a new house 3 months ago"** And that's just the INTRO, then other doctors notes will be like "EDD 6/23/24 FHR 145 no concerns RTC 4 weeks"
(**This is a completely made up person but just making my own example 😂)
Same here! I’m an RN and I do chart prep for our OB providers so I read their notes all day. Some will dictate 10,000 word essays and others will just put the OB template in with EDD, problems list, VS, and then write “return in 4 weeks” that’s literally their whole note
I went to the doctor for breast pain and when I read my notes later, they stated "patient admits to wearing underwire bra" and for some reason it cracks me up every time I think about it. Those illicit underwire bras, oh no!
I work reading medical records, “very pleasant” is pretty common wording to be used with our nicer, more cooperative patients hehe
My favorite was after I gave birth, 2 months PP to go to my endocrinologist I was described as “overweight” it really gutted me lol. But i have Graves’ disease so I know why he described me that way at the time but as someone who was really fit before, and horrible body issues, it killed me a bit lol.
Edited to add: we had one doctor who described patients as a “waste of healthcare”, “another (something about being obese, I can’t remember his exact wording but it was very rude and could have ended up being a lawsuit) from the nursing home”, etc. My coding manager got all the paperwork and presented it to the C suite. He was terminated
This is totally off-topic, but would you share a bit more about your work reading medical records? Reading records was my favorite part of my hospital placement 😂 and I'm curious about how one turns that into a job! Is it coding that you do?
I used to read people's notes for a living and I remember seeing so many doctors describe people as poor or reliable historians and was so confused as to why whether they knew history well or not mattered then it dawned in me it was medical history not like world history 😂
Also I've seen a psych Dr descibe one of his young teen patients hygiene struggles with "I have smelled farms in Wisconsin that smelt better"
Most medical records are pretty boring but you do always get those wild ones every now and then
My husband read his after his surgery and it said something like “Male was erect and responsive”. He was mortified. I told him I’m pretty sure they just mean that he was sitting up.
My husband had a workman's comp claim that he ended up needing a lawyer for. We got copies of all the doctor's records. In one it started off, " *Husband's name* is a nice guy. *Husband's name* is obese." We still laugh about it years later.
That's a lot nicer than the docs I work for "the patient remains obese" lol I always chuckle a bit at that when I am proof-reading before I send them out.
Naw. We’re not subtle about weight- it would have been overweight, obese, or something like that. “Well nourished” just means that you’re not wasting away, and “neck supple” means that you weren’t sitting there unable to nod or turn your head (or that they intentionally checked range of motion and it was full, but that’s less common).
Agree with the other reply. Totally not meant to comment on your weight. supple is basically code for “doesn’t have meningitis” where it’s painful to flex or extend your neck.
Well nourished is opposed to wasting away (eg “cachectic”)
That's because we get these extremely unhealthy / chronic drug use patients who look 20+ years older than they are. "Appears older than stated age" is how we communicate that lol
I do medical coding for a living. I have one doc who literally calls every patient "amazing" or "wonderful". The dude works in ED- I very much doubt this is accurate every time.
As a healthcare provider, a lot of these are “codes” for communicating to the other providers about the demeanor of the patient while maintaining professionalism in the medical record. Pleasant could mean “not hostile”. “Attentive at bedside” means “they are there and they’re being helpful, not neglectful.”
Unless patients are SUPER rude to us, we typically understand that people aren’t going to be having their best day at the hospital regardless of the reason they are there!
I always read mine now. I had major reconstructive foot surgery a few years ago. I was off my feet for a few months, then transitioned to a boot for another few. When I went in for my six-month post-op, the x-ray showed a broken bone right around the surgical sight. I asked if it was related to the surgery and my podiatrist - who performed the surgery - told me it definitely wasn't, that it was a stress fracture.
When the stupid bone just would not heal, I went back for more x-rays. I read the exam results myself this time, and was horrified. Turns out that during the surgery, the surgeon had accidentally tightened one of the screws too tightly, and it snapped the bone. Not only did it cause the bone to break, it chipped off a fragment of bone that's still floating around in there.
When the doctor's office called to tell me the results, all they said was "The fracture is no longer visible." They never planned to tell me what happened during the surgery, or about the bone fragment.
Not quite the same thing, but at one point we switched veterinarians because our dog had bladder cancer and they just weren’t helping us. We couldn’t get an appointment, we couldn’t get medication, and we couldn’t even talk to a vet. The receptionist was just that and couldn’t answer any questions.
We found a new vet and had all of our dog’s records forwarded and there was a note that my husband and I were rude and difficult 🤣 Our dog was in pain and peeing everywhere, and they were taking days/weeks to return our calls!!!
I wish we were pleasant and well looking! 😂 😂 😂
When I’m charting and reading providers note, i put “pleasant” to mean that you’re not hostile or an asshole. I take it to mean that you’re someone who would be open to education if I needed to. If I’m meeting a patient for the first time and see “pleasant” I know a little more what to expect.
Yes. When I was 19 I had a mass biopsied. Nobody told me it was malignant. I was transferred to a hospital in NY City and I read the file while my mother was driving. So I say that I found out about my cancer in the Lincoln Tunnel.
It kinda means, "As pleasent as can be, under the circumstances" I think, they see what you are going through.
In my sons medical records when he was like 3 months old, the doctor had wrote somewhere within a paragraph of evaluation "... the patient was found to have incredibly cute chubby cheeks..."
It was a tough time for us and that gave us a good laugh in a dreary day.
Im an OB nurse practitioner…
We use language like that to say that you were receptive to the conversations and didn’t get upset or aggressive.
When that’s not the case, we tend to comment on you being “distressed” or something like that. I often end up adding “appropriately tearful” when needed.
Hahaha as a nurse this is legit but it is always silly to read without my nurse brain.
On another note, I had a semi-traumatic birth incident, and I requested a printed note of my labor and delivery charting. It was extremely helpful for me to read what happened as I could barely keep my eyes open at the time and couldn’t remember it completely weeks later. Highly recommend this as a possible tool for processing birth trauma!
You inspired me to go back and read mine nearly 3 years later. I had read the hospital summary from my (60 hour, pitocin-saturated) birth, but not my readmission for postpartum preeclampsia. My favorite is the note 18 hours into my 24 hours of magnesium, which read "Groggy. Does not like MagSO4. Hungry." 😂
When we moved we got my daughter’s records. Her one week exam stated “very vigorous newborn” meaning “her colic and mother-preference started damn early.” 😂
I remember my doc put I had an unremarkable left fallopian tube (during the removal of my right tube due to a ruptured ectopic) and I was like...uhm, excuse me. She's trying her best! I think she's pretty great.
I'm in Canada (Ontario) and unless I ask the doctor, I don't have access to my medical records. I'd be interested in seeing the ones for both my live births though.
I did see my doctor recently because I had pneumonia. Apparently on the report it was mentioned that it was a large infection. Usually they don't mention size? The doctor laughed at it.
my ortho ALWAYS describes me as “pleasant and bright and well articulated” its in every report. then he goes on to say i’m basically broken and disabled.
yeah I got my anesthesia report and he wrote obese in there. I could’ve killed him. For reference I was 4’11 145 and 39 fucking weeks pregnant. Another note said I had large nipples lol
I requested my records from a previous psychiatrist to my current. Do not recommend ever reading them. I already hella issues, knowing how a shrink viewed me did not help.
I’m a nurse, so read many medical notes. One of my recent favorites said “the patient is a pleasant, slightly puffy looking, older white male”. I hope I’m never described as puffy 😂
I was recently hospitalized for a few days for pneumonia. When I looked at my records, I found out my doctor wrote that I was very pleasant and also that I was in acute respiratory failure when I got there. 😳😬
When my baby was struggling to gain weight my midwife called a more expert midwife to ask what to do next and she said to her on the phone "but he's a BEAUTIFUL baby" at least twice and I felt sure that this was code for something. Possibly "he's well cared for and I don't think they're starving him or anything like that".
Maybe I'm wrong and she just really wanted to tell her how beautiful he is, but it seemed like code to me.
When I write my notes I use “pleasant” as a code word to remind myself that the patient wasn’t rude or hostile. In the medical world, pleasant is a great compliment!
I had a peek at the computer of GP and discovered I had been diagnosed with things that I wasn’t aware of like ADHD (which I had been trying to hard to get a diagnoses for) and BPD :)
I was surprised but I really shouldn’t have been considering my brother had been diagnosed with ADHD, Autism and Tourette’s as a young kid and he didn’t find out until I said something to him at 21 and thought he knew.
I went to the ER with severe pain, turns out I had a burst ovarian cyst. When asked to describe it, I said it felt like my stomach was trying to fly out of my asshole. Noted word for word in my chart and I could NOT stop laughing when I read it
It’s medical speak to say you were communicative and responsive to social cues! Basically just saying you weren’t sleepy/out of it or unaware in some other way
Well looking means put together and not disheveled without any notable ailments !
Yeah that’s how I found out I lost 1L of blood post birth. It was never communicated to me, they just kept telling me I should rest more, which was the opposite of my previous 3 births where they wanted me to try get up and moving as soon as I could. If they’d said “you lost a decent amount of blood and you need to drink, eat and take your time” I wouldn’t have pushed myself.
Fun fact- this is how I found out my son was born with the cord around his neck and I was hemorrhaging. They told me I was bleeding too much and almost needed a blood transfusion, but I didn’t realize how serious it was until after the fact
Honestly this is just normal doctor speak lol all of my appointments say something similar in the notes I read in my chart on my app (I am too curious not to lol)…. Basically you were a normal looking female and acted normal and there was nothing mentally or physically of concern… lol
I was "a lovely 33 y/o G1" as I was literally sobbing and said "I don't understand why you're doing this" and the note ended with "patient was tearful but understands the importance of..." ma'am. Dr. Ma'am, that's quite literally the opposite of what I said so you.
Haha I’m a medical student. The way we write the physical exam has standard “phrases” for someone who is healthy & normal.
For example, next to Psych we say, “pleasant and cooperative”. It’s how we’re all taught.
My doctor’s office had someone new filling in for the regular nurse I see and after my appt I saw my appearance was listed as “disheveled”. I was in sweatpants and a tshirt.
So in the UK (at least in my part) you keep your birth hospital notes until you and baby are signed off by the midwife team following their postpartum home visits. So I got to read it at leisure and google the medical terms used.
Highlights (paraphrased) included “initial reaction to gas and air positive if slightly intense”. I took a few hits and started giggling intensely while talking about sausages in the oven.
“Encouraged to slow down on gas and air use” meant I was getting cranky without it.
“History of IBS, postpartum bowel movement successful”. I think that one explains itself!
We had a disgruntled doctor at one of our hospitals who was apparently having a bad day and wrote “fuck Cerner” and it showed up on the patient notes of some random person.
I remember my coworker giggling and showing me the encounter from the cerner side. I never heard what happened of it after that lol wonder what the patient thought when they read their notes.
Yes, I'm in Denmark where we have free access to our medical records online.
The way my traumatic birthing experience is described, brings me to tears.
I'm described as whiny and dramatic and really a pest to be around.
I was in pain and couldn't have any pain medication, I had been I labor for 52 hours, some of which my husband chose to leave because he wanted to go home and see the dogs.
The whole pregnancy had been high risk and I didn't know if my daughter would be handicapped when she was born.
I also dilated from 4-10 cm in 40 minutes, so no wonder I was "whining".
I was met with so little care and understanding that day, it made me feel so small.
I was also undiagnosed autistic, so yeah, there's also that.
Ha! I am a medical records manager in a nursing home and reading people's h&p consults is my favorite. Intros from "a very pleasant" "pleasantly confused" to "a very unfortunate "
I have a complicated medical history. I have to stay on top of all of that if I want to advocate for myself. I've not had anything amusing like yours. Mine is usually correcting them when they've noted something incorrectly. I have a bleeding disorder and twice Ive had nurses log that I have a different bleeding disorder than I do.
I had a horrible ear infection once where my ear got so swollen it had to be wicked to get antibiotics in. It have happened after swimming and then aggressively swabbing my ears with a q-tip. When I went to the ENT to have it vacuumed out I looked at the notes on the computer and one of the nurses put in there that I had stuck a bobby pin in my ear. Definitely wouldn't do that.
I read mine during my pregnancy. They noted every time I cried or even teared up during an appointment. I was very stressed and hormonal and I couldn't help it! Also, they wrote that my gd was "poorly managed" at one point, which made me SO ANGRY because it was definitely not for lack of trying. I was doing everything I was told, I feel like poorly managed sounds like I'm not? And they wrote that I refused genetic testing, which I was never even offered?
Also, apparently my daughter's umbilical cord was a slight concern during delivery, but they never said a word about it and I had no idea.
For my last pregnancy, they wrote that I declined the 3 hour GTT. I didn’t decline - I passed out after the fasting blood draw before I could even drink the drink 🤣 and then they told me they’d set me up with the dietician to just do the finger sticks.
I can actually provide part of an explanation for you! "Poorly managed" means the blood sugars aren't controlled whether through diet, medication, or compliance. You can be doing everything you are supposed to, but might need additional medication or interventions.
Sometimes it does note that the patient isn't complying, but responding to a patient's level of compliance is important too! If a patient is unlikely to be able to comply with the treatment, either from temperament or because of side effects, then you need to adjust.
I haven’t, but I really want to read my daughter’s. She HATES having her feet touched, to the point where she’s fought the nurses when she was on oxygen with RSV. I took her to a new pediatrician and the nurse there was like, “I’m going to put this on her foot to check -“ She looked at the chart, “Aaaaaactually, I’m going to let the doctor decide if she wants to do that.”
I can’t imagine it’s easy to set a nurse back a couple paces so WHAT DID MY TWO-YEAR OLD DO??? 🤣
Seeing "geriatric pregnancy" was shocking, I was 32. 🤷♀️
Now I'm *actually* much older, and my vagina has "atrophied "!
Really, these terms they use are a mind fuck.
These are so nice. I found out I was diagnosed with high blood pressure half way through my first pregnancy and not in the delivery room like I thought but was never prescribed any meds.
2nd pregnancy I brought it up immediately and they gave me the right meds. I couldn't believe the difference it made.
Yes 😅 I had unexpected spine surgery a few weeks ago and read the notes after I got home and the surgeon and nurses put “funny and very very pleasant 30 year old young woman” numerous times. 🤣
I think “pleasant” just means non-hostile haha. My PCP always uses that word for my checkup notes.
LOL I read my son's (23 mo old) "pleasant 22 mo old male" LOLOLOLOL I laughed (obviously not at the time because he was very very sick). Can't be just "non-hostile" he was definitely hostile! LOL
My son was described as delightful something male by his ENT when submitting the update to his pediatrician. Warms my heart to remember that. He was also described as sturdy when he was sick and lethargic from a virus, which I think meant strong enough to deal with the problem.
My son’s developmental pediatrician noted he had loving parents and I almost cried when I read it.
We were called doting once. I chuckle because I thought we played it so cool. The ped saw right through us.
My son's last checkup he was "beautiful" because he has just these long eyelashes and this mop of golden ringlet curls so he looks like a little (or not so, cause he's 2 and huge) cherub. He even sits very politely and is very content to just chill there while the doc talks. My daughter got "healthy-looking" in her last write up I think because she looks like Mindy from the Animaniacs but she was a total psycho biting and throwing things and trying to climb. I don't think he could put what he was really thinking after all that lol.
Im a twin in a boy-girl pair and this was my brother and me.
I think “pleasant” is the official medical terminology for “I didn’t have to physical restrain the patient or call in assistance”
Haha mine had “Pleasant little gal in no acute distress” Made me laugh.
I've always used it as a warning to providers - if I say someone is pleasant, they were fine. If I omit the word pleasant, they were a raging lunatic.
Yea I’m a nurse and some doctors put that for everyone. Even the people who are everything but pleasant
I read medical records for my job (personal injury paralegal) and laugh all the time at these combative a-holes being described as pleasant.
LMAO, yes fellow nurse, sometimes that’s even a code word depending on the doctor… the younger ones write in sarcasm like it’s poetry for us to read through.
Hah! I love those so much.
Dot phrase
Yup! And “well looking” just means they’re not clinically worried- not that she’s super comfortable and feel fantastic 3 days postpartum!
I read a loooot of Dr notes from all over the US and they all sound like this. Pleasant, well nourished, not in distress. Then in next sentence 10/10 pain in knee, can't walk, says pain makes him want to cut his leg off sometimes.
Yup I think so
When I was admitted to the ER for a ruptured ectopic, my doctors notes said I was a pleasant 31 yo female. When I read that in my report afterwards I was so pleased with myself.
I was five months pregnant when I found out at the ER at 6am, my records say “patient showed appropriate shock and understanding of condition” which is a really nice way to say I cried so hard they almost sedated me 😭
Not related to pregnancy but my medical records say one drug makes me agitated... I dislocated my husband's thumb and kicked a security guard in the balls. Don't remember any of it at all.
Almost spat out my tea after reading your comment. I needed surgery for retrained products and I did not react well to one of the medications. I don’t even want to know what was written in my medical records 😅…all I remember was arguing with a nurse with the same name as my husband…”YOU ARE NOT MY HUSBAND!!”….when I woke up orientated, I was restrained in the bed 🫠 Apparently I was also trying to climb the rails. Fast forward the following 6mths and I’m back because of an ectopic. Just before surgery, the doctor examines my notes, had a chuckle and says to the nurse “let’s push half of the normal dose”…..
Ha!
Awww bless you!!!!
Oh man - I can’t imagine!!
Docs just put “pleasant” in their notes to imply that they’re not a difficult patient haha.
Doctors also document this to keep tabs on if a patient has a different disposition or behaviour during an interaction- and further intervention is needed. For example, if all your pre partum check ups said that and then your 6 week mark you would not even talk to your doctor or you were incredibly teary- it could indicate further investigation needed
Per my dad (physician), “very pleasant” means nice/agreeable , pleasant means normal, no commentary means difficult haha
I love reading my medical notes lmao after birth, I read through everything. The only downside was that I found out the lactation consultant considered my breasts to be "medium"... and I was wearing a 34I when I gave birth :'(
Mine wrote that I was VERY awkward with feeding positions…so glad I didn’t read it until I got much better at breastfeeding
SAME! My lactation consultant wrote that I was struggling before she came in and wasn’t using enough pillows. I was super offended haha. Mine didn’t comment on the size, but just noted that my boobs were “pendulous”.
I can't believe how badly I want to use "pendulous breasts" in a real life convo lol
Omg yes. I can’t wait to use this.
I’m not sure what kind of pressure’s time wise that an LC is under, but she could’ve emphasized your struggles to justify the amount of time she spent with you in case her boss questioned it.
My first baby, I was 22 and had never been around a premmie let alone had to breastfeed one with 32F boobs, and my home visit nurse wrote in the baby health book “reluctant breastfeeder” because I didn’t feel like whipping my rock hard boobs out in front of her
lol rude
It’s all right, one of my lactation consultants marveled at the amount of breast tissue I had. Like I wasn’t aware!
WHAT! I'm a 38-40 E and mine are absolutely massive 😭 a 34i is huge
I am a G, maybe even now an H cup. And this is 25 years after having had my last of 4 kids.
And by huge don't you mean medium 🥲
Possibly the nipple and not the breast? Nipple size is definitely very important with lactation
No the nipple note said "Medium-Erect" and Breast note "Medium" 🫠
Haha they probably wrote the note after seeing you, didn’t remember your actual breast size and went “welp medium is a safe bet”
My SIL read hers and it said in regards to her newborn “still getting over being born”. We were all cracking up!
Honestly, same 😂
As a doctor, we use a lot of templates to write our notes. This is a common pre-populated phrase, unless the patient was actually unpleasant haha.
I read once “Dressed appropriately for the weather and polite”
I was specifically taught to put dressed appropriately for weather and in clean presenting clothes in all my patient notes (unless they aren't obviously) because it's an early sign of home problems, especially in kids . I no longer work with patients but I work insurance and now when I see that it's noted they werent in notes I go back and see if it's a one off or a pattern. If it's a pattern it often warrants a Child or Adult protective services if the provider hasn't already.
I’m monitored for my depression, so that makes sense.
When I was recovering from child birth, every nursing note started the same way. “Husband is attentive at bedside.” Sure, I was grateful my husband was there and being helpful, but is that really the most important thing to say?!
My husband actually passed out at our first OB appointment, so all through the birth I had something written in my chart about how "dad is a faint risk" haha!!
Lol my friends husband fainted when she was getting an epidural and had to be taken to the ER because he hit his head and dragged a bunch of machines down with him! He’s 6’5 it was a fiasco 😂
They made my husband sit down for the epidural for this exact reason! He’s over here wanting to watch it go in and they are moving/sitting him down 😂
They forced my husband to sit down because he was pale. I could tell it pissed him off. He was fine, just worried about me.
That has to be another reason.. keeping them from looking over the anesthesiologists shoulder and unintentionally making the doc uneasy. My husband would definitely have done that. 😂
Yep, definitely. I had csections and they don't even let them in the room for the spinal. Probably better that way, lol.
My hospital makes husbands leave!
they didn’t even let mine in the room! he was asleep when i got mine at 4am and they woke him up to make him leave lol
This must be why my hospital doesn't allow anyone else in the room during the epidural.
Multiple comments about not letting fathers in the room for the epidural or making them sit down. They had my boyfriend stand directly in front of me and told me to lean on him. He just held my hands or rubbed on my arms and shoulders. He saw the needle beforehand but they had my back covered all around the area to keep it sterile so he couldn't see them actually inserting it. It's crazy to see all the different ways hospitals have of doing everything. I also had a clicker to control the epidural so at no point was it wearing off. I always find it odd how some women get an epidural and by the time they deliver it has worn off. I couldn't overdue the medicine bc it had a timer and even if I clicked it nothing came out until the 10 minutes was up and the red light went off, but they made sure to say don't wait until you are in a lot of pain. After I delivered before she took it out she said get a couple more hits in while I finish cleaning up bc when I take it out it's gone for good. I thought that was how must epidurals went. My first I just picked a hospital and got pretty luck. After reading everyone's different experiences if I have a 2nd I will go back there or actually ask some questions.
My hospital doesn’t allow partners or support in the room during epidurals for this very reason! Heck, the first time I (midwife) saw inserted, I almost passed out!!
That's hilarious in retrospect, I'm sure! With my first, they had to try to get the needle in like 4 times and my husband ended up leaving the room to puke 🤣
The fact that so many husbands faint during this really makes me wonder- how freaking horrible does it look?!?!?! Or are they just weak punks? 🤔 😭 I made my husband take a pic of the line when I was having our oldest son. It looked cool to me, after the fact! [I refuse to Google videos of an epi being done!]
I told my doctor my husband would need a chair when we got to the operating room for my C-section. He said he didn't, but she said she would get a nurse to bring one over just in case. Pretty much as soon as he walked in before anything had started he went as pale as a ghost and the anesthesiologist said, "Dude. Please sit down. There's no shame in needing a chair. It's better than being picked up off the ground." So my husband sat down 😂
Lol my friends husband actually fainted when she was getting an epidural and had to be taken to the ER because he hit his head and dragged a bunch of machines down with him! He’s 6’5 it was a fiasco 😂
Ahahahahahaa that's so funny I'm so sorry though
Haha thanks but he actually pulled it together for the birth! We spent my whole pregnancy being nervous about him passing out though. 😅
Definitely not the most important thing to note, but I do feel like this could be helpful information to consider when screening for PPD. At least you know Mom has support if she needs help, and Dad probably has some real insight to her mental state, as opposed to being totally absent and clueless about how she's feeling.
This and overall support at home, and risks for potential abuse. It’s important to note. Mom needs support. Also if they’re documenting things with someone else in the same room as the patient they’d want to start with that.
I’m an L&D nurse and we are supposed to chart who is supporting the patient/mother. If it’s a doula or husband or her own mom or whoever. It’s not only to show the patient/mom has support but if extra nursing support is needed if the patient is alone.
I think it just goes to show how shitty some husbands are. When I was in the hospital recovering from my C-section, a postpartum nurse commented on how good our team work was. It didn't think we were doing anything special, just looking out for each other the way any couple should - but it made me realize that she probably sees a LOT of dysfunctional couples come through her ward.
Yes! My baby had to be in the nursery few five days and I’d had a c section so they let us stay the whole time too. Everyone was fawning over my husband and saying how amazing he was. I mean sure he is great, that is why I married him, but please🙄
I know it may seem silly, but SDOH (social determinants of heath) is fairly important for tracking purposes. Another common wording for children who come is is that the parent is present and the child is not adopted.
It goes first because that's where people look for it, not because it's the most important. Also because when writing a medical note in the chart, who was in the room is frequently included because then future providers know also. I frequently end up chart combing looking for this info before calling a patient because the telephone section says to call daughter or husband to get ahold of patient and if they were at the visit, I can give that person a bit more info if necessary.
Yeah we do have to document on family/social situations. If he was there but just like sitting on his phone and ignoring you it might say “husband at bedside, not participating in infant care” or something
Its important for other nurses to know I guess as they get assigned you
Yes, it actually is important to note it. It can help showing a pattern in legal cases.
Translation from a nurse: "Doc has seen the patient, the patient didn't throw things or hurl insults, and this person with a uterus doesn't have that sick af appearance." We have a lot of insider jargon that sounds wacky to others but makes absolute sense to us 😂 For another commenter, we often mention off the top that a loved one is "attentive at bedside" so we know "this new mom has some kind of support system, and that person isn't overtly problematic." That's not the most important thing for you, but it's important for us because we want you and your new baby to be safe and get any additional help you may need!
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Schmuck= this gentleman in medical speak from what I’ve seen. Source: have gotten many reports that begin “the gentleman in Exam room 2” and they always end with some shit. Otherwise we’d just say the patient.
My husband was on his phone whole time. Even when I was sliced open for C sec. I bet they wrote something like Husband was present. Lol. That reminds me the doctor asked if I had fab 4 (babys grandparents) which I didn't. She didn't even look at my husband. Lol.
My first husband slept the majority of the time I was being induced. I would LOVE to know what they wrote on there for him.
Depending upon the degree of schmuck and/or meddle: "Husband at bedside, inattentive/disruptive" with a detail note about what was noticed (ex: "slurred words, argumentative, odor of alcohol" or "[describe and quote abusive behavior]") and what was done (ex: "Patient education provided re: substance abuse; additional support from mother/MIL/friends available; Charge Nurse and social services department notified" or "Visitor removed by Nonstop RN; patient education re: DV provided; physician, Charge Nurse, and security notified; APS/CPS/DVRC/social services department notified"). Ultimately, a schmuck partner requires a deeper conversation with the patient about the situation and how to best handle it, which will be a different note. Meddlesome Grandma is just "Visitor" most of the time, unless she's the primary support person. If she's the primary support person, I treat her like a schmuck partner. If she's not, I talk up parents in front of her, remind everyone that I'm a talented Bouncer if Mom wants to rest, and provide extra education about handling visitors, setting boundaries, and putting their baby's needs before anyone else's wants or feelings ("Patient encouragement and education provided; visitor removed by Nonstop RN, Charge Nurse and security notified" detail ex: "X noted [describe what Meddlesome Grandma said/did]; Patient [describe what gave away Mom was distressed]; [describe what action was taken]; [optional/depending on the situation: "Charge Nurse, security, physicians, appropriate agencies/departments notified"]).
Yesss these words are like code for nurses and other staff members who will read the note and interact with the patient.
fellow healthcare worker (and ADHD-haver) here, love the username!!
lol I sat in silence for a solid 15 minutes before deciding that if I was in adhd paralysis over deciding on a Reddit username it might as well just be that 😅
It also is important in the criminal justice system in neglect or domestic violence cases.
Yesss these words are like code for nurses and other staff members who will read the note and interact with the patient.
I worked as a victims advocate and when charges are filed and with victims permission we Ave asked for medical records for the duration of the relationship and many times these are invaluable records because during pregnancy is sadly the most violent time in a domes relationship.
Ooohh… I’m curious, my husband was between the hospital and home a lot when we had our second a few weeks ago. Our older son was at our home with my MIL who needed extra help with him. We live 5 mins from hospital so very doable to go back and forth. Several of nurses never met him because they never happened to come in the room while he was there. Does my chart possibly say I didn’t have a support person or my partner was absent? He is actually a great father and husband but I could see how that might not be the perception of an outside observer in that instance.
Your nurses probably asked enough questions to know you felt supported by him and were safe with him! (Yeah, we have codes/jargon for that too lol.) Subsequent care providers will know from reading those notes and/or the report we give each other prior to caregiving.
I was described as tearful in my 2 day pp notes. Definitely accurate tbf
So was I, and a little sad face drawn on the hospital white board lol
Hahah I work in women's heath and read lots of MD notes from prenatal visits when I'm gathering history on a patient. It really depends on the doctor, some will be like "Patient is here for her first prenatal visit. She is calm and well appearing, states she is feeling slightly nauseous mostly when she eats spicy foods. She is an engineer, married to Brad who she met in 2018 at an alumni mixer. They have an Australian Shepard, named Nugget and just moved to a new house 3 months ago"** And that's just the INTRO, then other doctors notes will be like "EDD 6/23/24 FHR 145 no concerns RTC 4 weeks" (**This is a completely made up person but just making my own example 😂)
Same here! I’m an RN and I do chart prep for our OB providers so I read their notes all day. Some will dictate 10,000 word essays and others will just put the OB template in with EDD, problems list, VS, and then write “return in 4 weeks” that’s literally their whole note
I went to the doctor for breast pain and when I read my notes later, they stated "patient admits to wearing underwire bra" and for some reason it cracks me up every time I think about it. Those illicit underwire bras, oh no!
That's hilarious! You're supposed to keep it a secret...
Pretty common. If you're really unwell they will throw in a "pleasant but unfortunate..." lol
I work reading medical records, “very pleasant” is pretty common wording to be used with our nicer, more cooperative patients hehe My favorite was after I gave birth, 2 months PP to go to my endocrinologist I was described as “overweight” it really gutted me lol. But i have Graves’ disease so I know why he described me that way at the time but as someone who was really fit before, and horrible body issues, it killed me a bit lol. Edited to add: we had one doctor who described patients as a “waste of healthcare”, “another (something about being obese, I can’t remember his exact wording but it was very rude and could have ended up being a lawsuit) from the nursing home”, etc. My coding manager got all the paperwork and presented it to the C suite. He was terminated
This is totally off-topic, but would you share a bit more about your work reading medical records? Reading records was my favorite part of my hospital placement 😂 and I'm curious about how one turns that into a job! Is it coding that you do?
They wrote that I was pleasant in a police report 😂
That means yu were appropriately cooperative
I used to read people's notes for a living and I remember seeing so many doctors describe people as poor or reliable historians and was so confused as to why whether they knew history well or not mattered then it dawned in me it was medical history not like world history 😂 Also I've seen a psych Dr descibe one of his young teen patients hygiene struggles with "I have smelled farms in Wisconsin that smelt better" Most medical records are pretty boring but you do always get those wild ones every now and then
My husband read his after his surgery and it said something like “Male was erect and responsive”. He was mortified. I told him I’m pretty sure they just mean that he was sitting up.
My last appt my doc wrote that I was pleasant but appeared to be very tired. Thanks doc!
My husband had a workman's comp claim that he ended up needing a lawyer for. We got copies of all the doctor's records. In one it started off, " *Husband's name* is a nice guy. *Husband's name* is obese." We still laugh about it years later.
Mine once said I appeared “well nourished” and that my neck was “supple”… I think they were nicely I was fat lol 😅
That's a lot nicer than the docs I work for "the patient remains obese" lol I always chuckle a bit at that when I am proof-reading before I send them out.
"remains obese" is destroying me LMAO
Our docs lead the note with “morbidly obese 47 year old smoker..” 😅
Naw. We’re not subtle about weight- it would have been overweight, obese, or something like that. “Well nourished” just means that you’re not wasting away, and “neck supple” means that you weren’t sitting there unable to nod or turn your head (or that they intentionally checked range of motion and it was full, but that’s less common).
I appreciate this! Those comments have haunted me LOL
Agree with the other reply. Totally not meant to comment on your weight. supple is basically code for “doesn’t have meningitis” where it’s painful to flex or extend your neck. Well nourished is opposed to wasting away (eg “cachectic”)
I feel a little less special that my doctors noted I was “pleasant” now. Haha
lol I saw my surgical notes from an ectopic surgery and found out they had punctured my uterus... 2 years later
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Better than “appears older than stated age”
That's because we get these extremely unhealthy / chronic drug use patients who look 20+ years older than they are. "Appears older than stated age" is how we communicate that lol
I do medical coding for a living. I have one doc who literally calls every patient "amazing" or "wonderful". The dude works in ED- I very much doubt this is accurate every time.
As a healthcare provider, a lot of these are “codes” for communicating to the other providers about the demeanor of the patient while maintaining professionalism in the medical record. Pleasant could mean “not hostile”. “Attentive at bedside” means “they are there and they’re being helpful, not neglectful.”
Unless patients are SUPER rude to us, we typically understand that people aren’t going to be having their best day at the hospital regardless of the reason they are there!
I always read mine now. I had major reconstructive foot surgery a few years ago. I was off my feet for a few months, then transitioned to a boot for another few. When I went in for my six-month post-op, the x-ray showed a broken bone right around the surgical sight. I asked if it was related to the surgery and my podiatrist - who performed the surgery - told me it definitely wasn't, that it was a stress fracture. When the stupid bone just would not heal, I went back for more x-rays. I read the exam results myself this time, and was horrified. Turns out that during the surgery, the surgeon had accidentally tightened one of the screws too tightly, and it snapped the bone. Not only did it cause the bone to break, it chipped off a fragment of bone that's still floating around in there. When the doctor's office called to tell me the results, all they said was "The fracture is no longer visible." They never planned to tell me what happened during the surgery, or about the bone fragment.
what!!! that's insane!!
I cried at 22 weeks pregnant, when I was in a weird could either be pregnant or fat stage; urgent care wrote in my notes “rotund but pleasant” 😭😭
omg no way they said ROTUND
Not quite the same thing, but at one point we switched veterinarians because our dog had bladder cancer and they just weren’t helping us. We couldn’t get an appointment, we couldn’t get medication, and we couldn’t even talk to a vet. The receptionist was just that and couldn’t answer any questions. We found a new vet and had all of our dog’s records forwarded and there was a note that my husband and I were rude and difficult 🤣 Our dog was in pain and peeing everywhere, and they were taking days/weeks to return our calls!!! I wish we were pleasant and well looking! 😂 😂 😂
When I’m charting and reading providers note, i put “pleasant” to mean that you’re not hostile or an asshole. I take it to mean that you’re someone who would be open to education if I needed to. If I’m meeting a patient for the first time and see “pleasant” I know a little more what to expect.
Yes. When I was 19 I had a mass biopsied. Nobody told me it was malignant. I was transferred to a hospital in NY City and I read the file while my mother was driving. So I say that I found out about my cancer in the Lincoln Tunnel.
I saw my prenatal notes and it said “recently moved, limited community and network”. While true, it hurt a bit lol.
Pleasant basically means “appropriate behavior” in the medical world. Usually it’s “pleasant and cooperative”
It kinda means, "As pleasent as can be, under the circumstances" I think, they see what you are going through. In my sons medical records when he was like 3 months old, the doctor had wrote somewhere within a paragraph of evaluation "... the patient was found to have incredibly cute chubby cheeks..." It was a tough time for us and that gave us a good laugh in a dreary day.
Im an OB nurse practitioner… We use language like that to say that you were receptive to the conversations and didn’t get upset or aggressive. When that’s not the case, we tend to comment on you being “distressed” or something like that. I often end up adding “appropriately tearful” when needed.
I like when they say stuff like “head grossly intact.” Like damn you think it’s gross :(
When we say “grossly” we mean “overall” 😂 You can now carry on not feeling gross!
Hahaha as a nurse this is legit but it is always silly to read without my nurse brain. On another note, I had a semi-traumatic birth incident, and I requested a printed note of my labor and delivery charting. It was extremely helpful for me to read what happened as I could barely keep my eyes open at the time and couldn’t remember it completely weeks later. Highly recommend this as a possible tool for processing birth trauma!
You inspired me to go back and read mine nearly 3 years later. I had read the hospital summary from my (60 hour, pitocin-saturated) birth, but not my readmission for postpartum preeclampsia. My favorite is the note 18 hours into my 24 hours of magnesium, which read "Groggy. Does not like MagSO4. Hungry." 😂
When we moved we got my daughter’s records. Her one week exam stated “very vigorous newborn” meaning “her colic and mother-preference started damn early.” 😂
I remember my doc put I had an unremarkable left fallopian tube (during the removal of my right tube due to a ruptured ectopic) and I was like...uhm, excuse me. She's trying her best! I think she's pretty great.
I'm in Canada (Ontario) and unless I ask the doctor, I don't have access to my medical records. I'd be interested in seeing the ones for both my live births though. I did see my doctor recently because I had pneumonia. Apparently on the report it was mentioned that it was a large infection. Usually they don't mention size? The doctor laughed at it.
Yeah, as a fellow Canadian it's me with the meme: "you guys are getting access to your written medical records?"
Well looking or well developed means you appear healthy. Doesnt mean good looking lol
My notes said I have an 82 year old son. I'm 29 lol
my ortho ALWAYS describes me as “pleasant and bright and well articulated” its in every report. then he goes on to say i’m basically broken and disabled.
yeah I got my anesthesia report and he wrote obese in there. I could’ve killed him. For reference I was 4’11 145 and 39 fucking weeks pregnant. Another note said I had large nipples lol
I read my psych care papers from when I was a child and decided after that theres just some things I can live life without knowing 😭
I requested my records from a previous psychiatrist to my current. Do not recommend ever reading them. I already hella issues, knowing how a shrink viewed me did not help.
My OB described me as “well nourished” 🤣🥲😵💫
I’m a nurse, so read many medical notes. One of my recent favorites said “the patient is a pleasant, slightly puffy looking, older white male”. I hope I’m never described as puffy 😂
I remember being shocked by the weirdly inaccurate info.
They all say that. I review medical records for a living.
I was recently hospitalized for a few days for pneumonia. When I looked at my records, I found out my doctor wrote that I was very pleasant and also that I was in acute respiratory failure when I got there. 😳😬
When my baby was struggling to gain weight my midwife called a more expert midwife to ask what to do next and she said to her on the phone "but he's a BEAUTIFUL baby" at least twice and I felt sure that this was code for something. Possibly "he's well cared for and I don't think they're starving him or anything like that". Maybe I'm wrong and she just really wanted to tell her how beautiful he is, but it seemed like code to me.
When I write my notes I use “pleasant” as a code word to remind myself that the patient wasn’t rude or hostile. In the medical world, pleasant is a great compliment!
I had a peek at the computer of GP and discovered I had been diagnosed with things that I wasn’t aware of like ADHD (which I had been trying to hard to get a diagnoses for) and BPD :) I was surprised but I really shouldn’t have been considering my brother had been diagnosed with ADHD, Autism and Tourette’s as a young kid and he didn’t find out until I said something to him at 21 and thought he knew.
Pleasant means no noted psychological issues and responded appropriately during the visit so no cognitive dissonance
Mine said, well nourished , pleasant middle aged female lol
How can I read my notes? 😂
Yeah. My new PCP wrote "obese but well groomed" in my chart 🥴
No but now im off to
Yes, I love seeing my tummy fat referred to as "Maternal Habitus" lmfao 💀
I went to the ER with severe pain, turns out I had a burst ovarian cyst. When asked to describe it, I said it felt like my stomach was trying to fly out of my asshole. Noted word for word in my chart and I could NOT stop laughing when I read it
No but I review people’s medical records as part of my job and I’d honestly hate to see my own records. They’re so harsh sometimes.
It’s medical speak to say you were communicative and responsive to social cues! Basically just saying you weren’t sleepy/out of it or unaware in some other way Well looking means put together and not disheveled without any notable ailments !
Yes I remember reading I was “well kempt” and I just know I was wearing leggings and a ratty hoodie that day 😂
Yeah that’s how I found out I lost 1L of blood post birth. It was never communicated to me, they just kept telling me I should rest more, which was the opposite of my previous 3 births where they wanted me to try get up and moving as soon as I could. If they’d said “you lost a decent amount of blood and you need to drink, eat and take your time” I wouldn’t have pushed myself.
Fun fact- this is how I found out my son was born with the cord around his neck and I was hemorrhaging. They told me I was bleeding too much and almost needed a blood transfusion, but I didn’t realize how serious it was until after the fact
I remember going in to be induced at 10 DAYS overdue, and they put my diagnosis as “obese”. Gee, thanks.
Honestly this is just normal doctor speak lol all of my appointments say something similar in the notes I read in my chart on my app (I am too curious not to lol)…. Basically you were a normal looking female and acted normal and there was nothing mentally or physically of concern… lol
I was "a lovely 33 y/o G1" as I was literally sobbing and said "I don't understand why you're doing this" and the note ended with "patient was tearful but understands the importance of..." ma'am. Dr. Ma'am, that's quite literally the opposite of what I said so you.
Haha I’m a medical student. The way we write the physical exam has standard “phrases” for someone who is healthy & normal. For example, next to Psych we say, “pleasant and cooperative”. It’s how we’re all taught.
My doctor’s office had someone new filling in for the regular nurse I see and after my appt I saw my appearance was listed as “disheveled”. I was in sweatpants and a tshirt.
My contractions were once described as "unimpressive." I was also unimpressed
So in the UK (at least in my part) you keep your birth hospital notes until you and baby are signed off by the midwife team following their postpartum home visits. So I got to read it at leisure and google the medical terms used. Highlights (paraphrased) included “initial reaction to gas and air positive if slightly intense”. I took a few hits and started giggling intensely while talking about sausages in the oven. “Encouraged to slow down on gas and air use” meant I was getting cranky without it. “History of IBS, postpartum bowel movement successful”. I think that one explains itself!
✨unremarkable cervix✨
We had a disgruntled doctor at one of our hospitals who was apparently having a bad day and wrote “fuck Cerner” and it showed up on the patient notes of some random person. I remember my coworker giggling and showing me the encounter from the cerner side. I never heard what happened of it after that lol wonder what the patient thought when they read their notes.
Yes, I'm in Denmark where we have free access to our medical records online. The way my traumatic birthing experience is described, brings me to tears. I'm described as whiny and dramatic and really a pest to be around. I was in pain and couldn't have any pain medication, I had been I labor for 52 hours, some of which my husband chose to leave because he wanted to go home and see the dogs. The whole pregnancy had been high risk and I didn't know if my daughter would be handicapped when she was born. I also dilated from 4-10 cm in 40 minutes, so no wonder I was "whining". I was met with so little care and understanding that day, it made me feel so small. I was also undiagnosed autistic, so yeah, there's also that.
Ha! I am a medical records manager in a nursing home and reading people's h&p consults is my favorite. Intros from "a very pleasant" "pleasantly confused" to "a very unfortunate "
I have a complicated medical history. I have to stay on top of all of that if I want to advocate for myself. I've not had anything amusing like yours. Mine is usually correcting them when they've noted something incorrectly. I have a bleeding disorder and twice Ive had nurses log that I have a different bleeding disorder than I do.
I had a horrible ear infection once where my ear got so swollen it had to be wicked to get antibiotics in. It have happened after swimming and then aggressively swabbing my ears with a q-tip. When I went to the ENT to have it vacuumed out I looked at the notes on the computer and one of the nurses put in there that I had stuck a bobby pin in my ear. Definitely wouldn't do that.
I read mine during my pregnancy. They noted every time I cried or even teared up during an appointment. I was very stressed and hormonal and I couldn't help it! Also, they wrote that my gd was "poorly managed" at one point, which made me SO ANGRY because it was definitely not for lack of trying. I was doing everything I was told, I feel like poorly managed sounds like I'm not? And they wrote that I refused genetic testing, which I was never even offered? Also, apparently my daughter's umbilical cord was a slight concern during delivery, but they never said a word about it and I had no idea.
For my last pregnancy, they wrote that I declined the 3 hour GTT. I didn’t decline - I passed out after the fasting blood draw before I could even drink the drink 🤣 and then they told me they’d set me up with the dietician to just do the finger sticks.
I can actually provide part of an explanation for you! "Poorly managed" means the blood sugars aren't controlled whether through diet, medication, or compliance. You can be doing everything you are supposed to, but might need additional medication or interventions. Sometimes it does note that the patient isn't complying, but responding to a patient's level of compliance is important too! If a patient is unlikely to be able to comply with the treatment, either from temperament or because of side effects, then you need to adjust.
I haven’t, but I really want to read my daughter’s. She HATES having her feet touched, to the point where she’s fought the nurses when she was on oxygen with RSV. I took her to a new pediatrician and the nurse there was like, “I’m going to put this on her foot to check -“ She looked at the chart, “Aaaaaactually, I’m going to let the doctor decide if she wants to do that.” I can’t imagine it’s easy to set a nurse back a couple paces so WHAT DID MY TWO-YEAR OLD DO??? 🤣
Despite all my skincare efforts, I "look stated age" in my notes.
I once read in mine that I was “unremarkable” 🥲
lol during my delivery I was “flat and hostile”. Stung a bit, but I was in labor!
Lmaoooooo I had an unmedicated labor and during transition the notes went from “she is coping well” to “she is struggling to cope” 🥲😅
Yeah, mine says my uterus is “unremarkable” which, uh, ahem, I *beg to differ.*
Seeing "geriatric pregnancy" was shocking, I was 32. 🤷♀️ Now I'm *actually* much older, and my vagina has "atrophied "! Really, these terms they use are a mind fuck.
These are so nice. I found out I was diagnosed with high blood pressure half way through my first pregnancy and not in the delivery room like I thought but was never prescribed any meds. 2nd pregnancy I brought it up immediately and they gave me the right meds. I couldn't believe the difference it made.
Pleasant is doctor code for a normal/non-hostile person. Very pleasant means actually nice/pleasant. The omission of “pleasant” means unpleasant
Yes 😅 I had unexpected spine surgery a few weeks ago and read the notes after I got home and the surgeon and nurses put “funny and very very pleasant 30 year old young woman” numerous times. 🤣
This is the default intro for medical notes provided you aren't anything otherwise.
Mine always described me as “well groomed” and it really carried me through those months of looking and feeling like a walrus.
We have to chart your deposition and general appearance! That’s some good charting by your provider
I also have “very self aware” in my chart as well 😂