Calling all doctors, nurses, and transcriptionists… I was looking through some surgical reports and visit notes, and the phrase “The patient is a very pleasant gentleman” just seemed amusing. Do doctors ever describe a patient as “a horrible disagreeable lout” or “a barely tolerable individual”? Or was I exceptional in some way?
As secretary/office manager to a psychiatrist for several decades: YES. Usually phrased more professionally, but that’s what the sense boiled down to.
Edited to add: Note: Patients and others were NEVER given a chance to read raw, handwritten office notes.
I think they’re supposed to describe the patient’s attitude in general (toward his condition as a patient), the way he manifests himself in the presence of the medical staff, and how he accepts the diagnosis or the treatment.
I review medical records daily in my job. In relatively rare instances, they will describe someone as belligerent or such, but that is pretty uncommon. Most often when someone is intoxicated or drugseeking.
OTOH, it is extremely common for consultation notes to say something benignly complimentary, such as “Thank you for the opportunity to see this pleasant/interesting individual.” Or standard observations will comment on the demeanor. Such as “appears anxious/depressed.”
I’ll see how long it takes me to come across the next such comment.
In psych notes, there’s an outline for a formal status exam, and behavioral phrasing such as “did not comply with requests to x” is preferred to “belligerently refused to x.” Though preferred and less likely to result in a complaint, this standard is not always met.
I did temp work in the records room of an HMO one summer and it was lots of fun to sneak a peak at some of the records. There were a couple of famous people whose records I handled - I won’t name one because as far as I know they are still alive, but the other was Ruth Gordon. She was reputed to be a lovely soul - I don’t remember what her records said and wouldn’t share if I did, but I’m sure anything that was written about her affect was positive.
I’ve read a gazillion patient histories as part of my job as a pathologist, and it’s fairly common to see references to patients as nice people* (there’s even a mythology in the profession that the nicest folks get the most gruesome ailments)**.
Conversely, while there might be references to a patient’s hostile manner, this is couched in non-insulting phraseology. Every part of your medical record is subject to discovery by a hostile attorney, and that includes after the fact edits to electronic medical records. You don’t want to shoot yourself in the foot by being nasty on a report even under severe provocation.
*one surgeon I know often dictates that a very old patient is (for example) “85 years old, bless her heart”. The “bless his/her heart” may be a nice way of saying “it’s a miracle she got this far” or “end of the line, sweetie”.
**I have little to fear in this regard. 
***“sneaking a peek” at celebrity medical records is bound to get personnel fired these days unless they have a bona fide reason for doing so. Again, it’s easy to see who’s accessed an electronic record.
Such phraseology is not that unusual. Most patients are reasonably pleasant. Neutral phrasing might be used for more difficult people, except by the crustiest old surgeons who might be more precise.
It’s not so much the record could be subpoenaed; though there is that. It’s the implication that if the patient was perceived as unpleasant, they might not have received unbiased, optimal or professional treatment.
I have seen phrases similar to “the patient has an iconoclastic approach to personal hygiene” or “this unfortunate patient is on their sixth family doctor this year”. I guess it might depend on the potential audience.
“This well-nourished hypertensive male with Type 2 Diabetes…”
I see this sort of thing fairly frequently in clinic notes and admission notes. In the ED we tend not to bother noting that the patient is pleasant unless they are “pleasantly demented”. That lets any future providers know that while the patient is pleasant to deal with your history may be compromised and they may have difficulty understanding discharge instructions. If the patient was a significant problem that will likely make it into the note in some form. Extreme cases include “patient became profane and verbally abusive” or “patient obviously intoxicated and intermittently agitated, required chemical and physical restraint for the safety of patient and staff”. A less obvious case might be something like “patient had a number of concerns about their care while admitted including X, Y, Z. These concerns were discussed and addressed in detail” which tells any future providers that this patient is a high maintenance pain in the ass.
I don’t use these types of descriptions for patients, but I will sometimes have some fun with the date. I’ve documented some visits with things like “follow up in two weeks on the Ides of March” for a visit on 3/1.
I’ve seen notes where the physician went back and removed the “very pleasant” part. I know they went back because the template adds in “very pleasant” by default.
~Max
Oh yes, I see a lot of these too. Not only is it a warning to future providers (or even the same provider) who come across the record, it is also a good CYA maneuver to document when you have explained something to a patient in detail.
It is also a good bit of background in general. If you know going into the room that the patient has been informed about X by some other doctor (who you know is very good at explaining these things), then you don’t have to cover so much ground explaining how your specialty deals with X. You can see what subjects the patient is especially concerned about and tailor your initial explanation to tie into or preemptively address those areas of concern. Saves everybody time and confusion.
~Max
I read somewhere about someone noting on their dog’s veterinary records the abbreviation DSTO. They couldn’t find anything searching online, but eventually discovered the abbreviation means Dog Smarter Than Owner.
The funniest one I remember concerned a morbidly obese diabetic. At one point the record said something like, “She brought a Big Gulp of Mountain Dew to the appointment. I told her if she wasn’t going to stop drinking those, there was little medicine could do for her.” 
Some frequent visitors to ERs get notations such as, “Patient is well known to ER.”
I happened to have some medical notes from a shoulder injury a while back right here. In the notes the doctor said that I am “Pleasant, well nourished, and well developed” (also, my ‘neck is supple’).
I always just figured that was code for ‘not an asshole’.
Sound like your doctor is into you.
I saw this on a letter from my consultant to my GP and thought it was odd. Nice to know it’s just a bit of boilerplate.