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Discussion

Charting statements...

the following statements were found on patient's charts during a recent review of medical records. these statements were written by various health care professionals including (we're afraid) a doctor or two at several major hospitals:

"the lab test indicated abnormal lover function."

"exam of genitalia reveals that he is circus sized."

"the skin was moist and dry."

"the patient had waffles for breakfast and anorexia for lunch."

"she stated that she had been constipated for most of her life until

1989 when she got a divorce."

"the patient was in his usual state of good health until his airplane

ran out of gas and crashed."

"i saw your patient today, who is still under our car for physical

therapy."

"the patient lives at home with his mother, father, and pet turtle,

who is presently enrolled in day care 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."

"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 patient was to have a bowel resection. however, he took a job as

stockbroker instead."

"when she fainted, her eyes rolled around the room."

"examination reveals a well-developed male lying in bed with his

family in no distress."

Featured Replies

I have a physician who dictated wrong once. He had done a PFO closure on a young female patient and instead of the record showing that the patient's PFO was diagnosed by transesophogeal echocardiogram.... he had written that "diagnosis of PFO was verified with translady partsl echocardiogram"

Hmmmmm, I'm pretty sure I would have questioned him had he tried to look at my heart from that angle :)

one of my favorites is "pt in amb indep about unit in w/c" .... uhmm....:confused::smackingf

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