Medical Bloopers 3: A Medical Communications Defect
The following medical charting errors may appear funny to the casual reader but if they or their cousins are written in medical charts, they not only appear ambiguous but may in some cases be harmful for the safe and effective medical management of patients. These "bloopers" are the results of rushed notations with no rereading by the writer of what was actually written.
By the time he was admitted, his rapid heart had stopped, and he was feeling better.
Patient has chest pain if she lies on her left side for over a year.
On the second day the knee was better and on the third day it had completely disappeared.
She has had no rigors or shaking chills, but her husband said she was very hot in bed last night.
The patient has been depressed ever since she began seeing me in 1986.
Patient was released to outpatient department without dressing.I have suggested that he loosen his pants before standing, and then when he stands with the help of his wife, they should fall to the floor.
The patient is tearful and crying constantly. She also appears to be depressed.
Discharge status: Alive but without permission.
The patient will need disposition, and therefore we will get Dr. Shapiro to dispose of him.
Healthy appearing decrepit 67 year old male, mentally alert, but forgetful.
The patient refused an autopsy.
The patient has no past history of suicides.
The patient expired on the floor uneventfully.
Patient has left his white blood cells at another hospital.
The patient's past medical history has been remarkably insignificant with only a 45 pound weight gain in the past three days.
She slipped on the ice and apparently her legs went in separate directions in early January.
The patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room.
The patient had waffles for breakfast and anorexia for lunch.
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.
Since she can't get pregnant with her husband, I thought you would like to work her up.
She is numb from her toes down.
While in the ER, she was examined, X-rated and sent home.
The skin was moist and dry.
Occasional, constant, infrequent headaches.
Coming from New York, this man has no children.
Patient was alert and unresponsive.
When she fainted, her eyes rolled around the room.