Medical Records 101

By , May 25, 2010 3:25 pm

Problem:  INJURY – ARM (FOREARM AND WRIST)

Assess:  “Fell off couch & now limited movement, distressed with any attempt tomove (sic) arm.  Has croup like cough & black eye from cat.  PainStop @ triage.”


From this descriptive triage assessment, we can interpret:


1. That the child fell off the couch, and since that time is acting like a teacup.

2. Becomes distressed when no longer allowed to play that game.

3. Also has a cough.

4. And a black eye from the cat.  No need to try to make this funny.  That’s actually what they wrote.

5. Has given their contact details as painstop@triage.com

This triage assessment was initially confusing to me, until I read the doctor’s notes:

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Then it all made sense.

Brevity is the key to clarity.

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One Response to “Medical Records 101”

  1. Susan Nethercote says:

    Ha! I have a growing wariness of our medical system…..and humans……

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