Best MD note

[beckster_01]

There may or may not be a thread like this but I couldn't resist sharing. This weekend I was digging through my patient's chart trying to learn more about his history when I came across a note by the attending cardiologist. It said, and I quote: "Patient is stable, no complaints. Was screaming 'Kibbles and Bits!' repeatedly upon my arrival. Of note, patient does not have a dog." I couldn't help but laugh. Anybody else come across some interesting notes in their charts?

[IsabelK]

From a discharge summary from a hospital: "Recommend that patient follow-up with podiatry." I went to do an admission assessment to the LTC I was working in at the time as a unit manager. Bilateral AKAs.

"Patient's oxygen saturation was 98% on room air; respirations 0."

After an emergency removal of a rather personal item from a young man's rectum: "The vibrator has been cleaned. Tell the patient to stop sticking it in his ass."

[sevensonnets]

PPpppl

[Davey Do]

Just tonight, I was reading over a psychiatrist's H&P where he dictated,

"Patient says she is 126,000 years old, but appears to be much younger than stated age."

[sevensonnets]

Physician's note: "Patient states she has eaten the fork off her dinner tray. Will do stat xrays and transfer to psych unit."

[Penelope_Pitstop, BSN, RN]

"As a side note, patient resembles the rocker Alice Cooper. When I asked him if he had ever been told this, he smiled and said if he had a dollar for every time someone told him that, he would be a very rich man indeed."

[blackribbon]

My favorite discharge order was not a funny one but a compassionate one. The hospital was in a very poor neighborhood with a lot of homeless people. The patient was homeless and determined that it was safe to allow him to be discharged to his chosen "home". The patient was stable for discharge in the early afternoon but the discharge orders said "d/c after patient eats dinner in the pm".

[WKShadowNP, DNP, APRN]

One of my dictations had emulate instead of ambulate.

Another had activity instead of ectopy.

I need to enunciate better, I suppose.

[95PGTTech]

GCS 15 but confused.

Now I'm confused Doc...

To be fair, he is a very good ER DO, it was a bad night (heavy), we both took the opportunity to laugh. We are constantly making fun of each other's charting, which is as much cathartic as it is good practice to go back through and edit as necessary.

[GenieToBe]

My favortie was a FEMALE patient who underwent a TRANSlady partsL ultrasound. The results read: No testicular torsion noted.

:roflmao:

[Phil-on-a-bike]

Most mystifying one I ever saw said: "Thank you for reviewing this 50-year old gentleman, who is a member of the dark glasses brigade."

I had absolutely no earthly idea what it meant to imply, and neither did anyone else who read it at the time.

It was a historical entry and we couldn't track down the doctor who'd written it.

(Post Script: I just now googled "Dark Glasses Brigade" - apparently, a dated term for suspicious character in the espionage community! What the heck? This raises more questions than it answers!)

[Witty Kitty]

Blind patient brought to ER by EMS and seated in area where psych patients are awaiting medical clearance before being transferred to psych ER or held awaiting initial psych MD eval. Area also holds some medical patients, many requiring psych eval. I sit down with pt. and ask him why he's in the hospital. Pt. reports he received a phone call from a friend warning him to lock himself in the bathroom because someone was preparing to break into his apt. and rob him. hmmm, i think. i ask him if there was any chance that the "friend" calling him might be the one preparing to rob him (i mean he's blind, how would he know?). Anyway, pt. did not seem like a psych pt. but was triaged to psych just so he could be in the above mentioned 'secure' area for his own safety. Later, reading the Psychiatrist notes, psychiatrist writes, Pt. reports he received a call from "Jesus" warning him his apt. was going to be burglarized and that he should lock himself in the bathroom. Then Psychiatrist notes, "Jesus, his 'friend' NOT the religious character". I started cracking up because, in fact if that Psychiatrist had not clarified that and the Psychiatrist coming on for the next shift had read that note without that clarification, that next shift psychiatrist may very well have admitted that vulnerable, blind patient with no psych history because of the misunderstanding that the patient believed that the Son of God had called him on the telephone and warned him he was going to be burglarized! Without that seemingly comical clarification, who knows what chaos might have ensued for that little blind man....Suddenly admitted for psychosis he'd never even had!!! LOL

[Nursecliff]

We had a patient who was about 4'11" and kind of a pain in the butt--just argumentative and defensive about everything. The doctor handwrote "short guy syndrome" on a progress note.

I looked at it and thought "well, that's kind of unprofessional, but it's not wrong" before I realized that the doc had actually written "short gut syndrome."