Charting Bloopers - page 9
Found in the History and Physical section of a patient's chart who had experienced visual hallucinations while ill: "Patient vehemently denies any auditory, tactile, or old factory... Read More
Jan 12, '03I don't suppose this is an error but it was definitely different:
on the results from a UA
traces of talcum powder
Jan 14, '03The secretaries taking messages, more than once wrote:
Worried about Billy Rubin.
Yeah, He's a scary dude...
Jan 14, '03From a radiology order form: "CXR r/o Aplat's pneumonia"
Should have read: "CXR AP/LAT r/o pneumonia"....we only figured this out after trying to look up "Aplat's pneumonia" in several radiology texts and reference manuals.
Jan 14, '03".....Problems stemming from being an illegitimate child, due to the social MORAYS of the time..........." They really used to bite!
Jan 14, '03Here's one I saw today.
"Minor is 18 years old"
This was the probation depts way of letting me know a change occured.....Thanx,need to know!
Jan 15, '03The most recent funny charting transcription error I've come across was regarding Home O2.
The first one I read said "patient is on homo too"...The secomd one read"patient is a homo too". Wonder what the person who transcribed that dictation thought that was all about??LOL Esp since the rest of the dictation referred to the pts resp status!
Jan 17, '03Had a Doc at LTC who hated regulations and was a constant battle to get him to write dx for each med he ordered. After several requests he wrote dx for MOM order: can't sh**. Had to leave it on the chart....I'm sure surveyors saw it, but never said a word.
Jan 17, '03Not sure I'd call that a blooper. It was intentional and aimed at you. So rude and nasty yes... accidental no.:angryfire
Jan 17, '03I review medical records all day and have come across some really wierd ones.
"from both flebitis" (thrombophlebitis?)
"very close veins" (varicose?)
"patient is matching his eyes and his nose" (I's & O's?)
" no evidence of libido on lower extremities" (livido?)
"paralyzed with the neck team" (Anectine?)
"ptosis given @ 2 mu for induction of labor" (Pitocin?)
But I guess my all time favorite is "two lane hospital" (Tulane)
Jan 18, '03I think it's posted elsewhere on this site: the physician couldn't think of the correct name for the incentive spirometer, so he wrote: suck balls QID!
Jan 18, '03I've still seen thick, white drainage as ***** more than once. As a matter of fact just three days ago! What drove me crazy was that I was sitting there trying to think of the alternate term and could not remember "purulent". That Alzheimer's thing again!
Jan 18, '03Originally posted by Jay-Jay
I think it's posted elsewhere on this site: the physician couldn't think of the correct name for the incentive spirometer, so he wrote: suck balls QID!
Jan 18, '03No, no, the PATIENT was to carry out the order! Would have been an interesting sight to see.....