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Sunday, November 20, 2005

Hospital Chart Bloopers

Actual entries from hospital charts:

1. The patient refused autopsy.

Hospital Chart

2. The patient has no previous history of suicides.

Hospital Chart

3. Patient has left white blood cells at another hospital.

Hospital Chart

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

Hospital Chart

5. Patient has chest pain if she lies on her left side for over a year.

Hospital Chart

6. On the second day the knee was better, and on the third day it disappeared.

Hospital Chart

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

Hospital Chart

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

Hospital Chart

9. Discharge status: Alive but without permission.

Hospital Chart

10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.

Hospital Chart

11. Patient had waffles for breakfast and anorexia for lunch.

Hospital Chart

12. She is numb from her toes down.

Hospital Chart

13. While in ER, she was examined, x-rated and sent home.

Hospital Chart

14. The skin was moist and dry.

Hospital Chart

15. Occasional, constant infrequent headaches.

Hospital Chart

16. Patient was alert and unresponsive.

Hospital Chart

17. Rectal examination revealed a normal size thyroid.

Hospital Chart

18. She stated that she had been constipated for most of her life, until she got a divorce.

Hospital Chart

19. I saw your patient today, who is still under our car for physical therapy.

Hospital Chart

20. Both breasts are equal and reactive to light and accommodation.

Hospital Chart

21. Examination of genitalia reveals that he is circus sized.

Hospital Chart

22. The lab test indicated abnormal lover function.

Hospital Chart

23. Skin: somewhat pale but present.

Hospital Chart

24. The pelvic exam will be done later on the floor.

Hospital Chart

25. Patient has two teenage children, but no other abnormalities

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