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Discussion

Charting Bloopers

Have you seen any charting bloopers?

Found in the History and Physical section of a patient's chart who had experienced visual hallucinations while ill:

Quote
"Patient vehemently denies any auditory, tactile, or old factory hallucinations."

Featured Replies

I am reminded of the oldie but goodie from the infertility specialist who wrote to a consulting colleague, "Between the two of us, we should be able to get her pregnant"

...in an H&P...."hx of lady partsl hysterectomy for hemorroids."

Oh yeah?

Boy am I glad I didn't complain about my hemorroids!!HAHA

My favorite and most recent was probably a mistype by the unit secretary. Mr. Smith was to have a uterine culture. Now how would one accomplish that?

Rectal exam revealed a normal sized thyroid.

The patient had waffles for breakfast and anorexia for lunch.

The patient had been constipated for most of her life until 1989 when she got a divorce.

The baby was delivered, the cord clamped and cut and handed to the pediatrician, who breathed and cried immediately.

Between you and me, we ought to be able to get this lady pregnant.

The patient was in his usual state of good health until his airplane ran out of gas and crashed.

The patient lives at home with his mother, father, and pet turtle who is presently enrolled in daycare three times a week.

Bleeding started in the rectal area and continued all the way to los angeles.

Both breasts are equal and reactive to light and accommodation.

Since she can't get pregnant with her husband, I thought you would like to work her up.

Exam of genitalia reveals that he is circus sized.

She is numb from her toes down.

Exam of genitalia was completely negative except for the right foot.

While in the emergency room, she was examined, x-rated, and sent home.

The skin was moist and dry.

The lab tests indicated abnormal lover function.

The patient was to have a bowel resection. however he took a job as a stockbroker instead.

Occasional, constant, infrequent headaches.

Examination reveals a well-developed male lying in bed with his family in no distress.

Patient was alert and unresponsive.

When she fainted, her eyes rolled around the room.

She has had no rigors or shaking chills, but her husband says she was very hot in bed last night.

The patient has been depressed ever since she began seeing me in 1993.

The patient is tearful and crying constantly. she also appears to be depressed.

The patient refused an autopsy.

The patient left his white blood cells at another hospital.

  • Experts

My personal favourite real life blooper was one I saw on a report. A little background to this - we call the small Heat Moisture Excahnge units (HME's) that fit over a trachy "Swedish noses".

The charitng error

"Patient breathing well through Parson's nose"

  • Guides

The funniest thing I've ever seen in a chart was evidently the work of some medical transcriptionist who was new on the job:

"Patient has 3+ pitting edema bilaterally from knees to ankles. We will diurese her with Lasix 60 mg IV BID, watch her eyes and nose for a couple of days, and see if she improves."

SO glad the patient refused the autopsy!

  • Experts

I am currently giving IV Abx. to a patient, who, according to the client list I get from the office, has an "Infected Page Maker site."

Wow, that must have been SOME computer virus!! :D:D:D:D

There is, of course, the standard "husband stated pt. was hot in bed last night".

  • Admin

Admissions clerk note: Diagnosis: Pre-infarted angina.

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