Medical Bloopers: A Medical Communication Defect
The problem with these hospital chart bloopers is that they represent a failing on the part of medical students or even physicians who write notes in the chart. The failing is, either because of lack of time or interest, what is written is not read by the writer after the pen touches the paper. What I keep teaching my medical students about their write-ups is to read, read, and re-read what they have just written but to read their statements as some ignorant reader who has no knowledge regarding the clinical situation and decide whether they understand what was written and whether the words make sense. Ambiguous comments in the chart may be funny to read, as many of the statements below, but their presence represents a defect in the communication system and, in some case, may lead to misinterpretation and harm to the patient.
(By the way, I had already put up Bloopers 1-19 on a thread back on June 28, 2005.But they are fun to read so in case a visitor missed those, I republished them today but with 6 more that I found.) ..Maurice.
1. The patient refused autopsy.
2. The patient has no previous history of suicides.
3. Patient has left white blood cells at another hospital.
4. She has no rigors or shaking chills, but her husband states she was very hot in bed last night.
5. Patient has chest pain if she lies on her left side for over a year.
6. On the second day the knee was better and on the third day it disappeared.
7. The patient is tearful and crying constantly. She also appears to be depressed.
8 The patient has been depressed since she began seeing me in 1993.
9. Discharge status: Alive but without permission.
10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.
11. Patient had waffles for breakfast and anorexia for lunch.
12. She is numb from her toes down.
13. While in ER, she was examined, x-rated and sent home.
14. The skin was moist and dry.
15. Occasional, constant infrequent headaches.
16. Patient was alert and unresponsive.
17. Rectal examination revealed a normal size thyroid.
18. She stated that she had been constipated for most of her life, until she got a divorce.
19 I saw your patient today, who is still under our car for physical therapy.
20. Both breasts are equal and reactive to light and accommodation.
21. Examination of genitalia reveals that he is circus sized.
22 . The lab test indicated abnormal lover function.
23. Skin: somewhat pale but present.
24. The pelvic exam will be done later on the floor.
25. Patient has two teenage children, but no other abnormalities.