Bioethics Discussion Blog: Medical Bloopers 3: A Medical Communications Defect

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Tuesday, October 25, 2011

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.

This is actually the third in a series of such charting errors (the second in this series was an addition of 6 "bloopers" added to the original 19 and may be found at this link). There may be a few repeated from that second listing in this current presentation. Enjoy. ..Maurice.

Note: These "bloopers" come from a variety of sources and I don't know who to acknowledge for them.

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.



4 Comments:

At Thursday, October 27, 2011 6:49:00 AM, Anonymous Anonymous said...

Hahaha I have seen these before, but can't remember where. Still brings a grin.
Hopefully a patient wouldn't be harmed, as it doesn't take a genius to figure out what they really mean. A few red-faced people when they realize what they wrote I bet though.
TAM

 
At Tuesday, August 14, 2012 8:44:00 PM, Blogger SteveofCaley said...

I am very troubled by these "bloopers," which obviously could well have been fabricated. Who has such a free and broad range to so many medical charts?
They seem to reinforce a stereotype, and imply a comic classification of a group of people as this-or-that.
The only thing that separates this from bigotry is that doctors can be resented but not victimized, in the "conventional wisdom."
Many apologists for bigotry might state "but not my doctor," in the same way that people assure each other, "Some of my best friends are (Jewish, black, gay.)"
This presumes the arrogance of the speaker to promote individuals to full humanity (Ich-du) while leaving the unseparated lump of people in the denigrated class. (Ich-es).
Humor speaks volumes, whether Freud is out of fashion or no.

 
At Tuesday, August 14, 2012 9:02:00 PM, Blogger SteveofCaley said...

Moreover, not to come off as some sort of prim sourpuss, but I note a statement that deserves a comment:
"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."
Upon what is that assertion founded, other than a long legacy of un-analyzed thought, repeated as gospel, down the medical education tree?
One of the most amazing skills that is nearly lost from our culture is the ability to listen to someone so hard as to feel their essence speaking. This, if anything, is one of the few cardinal skills which will be a faithful servant during practice.
In the custom of our notes, we reach the "intellego" - a concept in Latin meaning "to understand, comprehend, see."
Clumsy prose by the note-taker is simply tangential to the process by which we practice. A reader of the chart who cannot practice "dia-gnosis" or the seeing-through of obscurity, might err in the care of patients who are "hot in bed." That old bugaboo on charting accuracy is a fairy tale, constructed as fairy tales are to explain the complex and tragic.

 
At Tuesday, August 14, 2012 9:11:00 PM, Blogger Maurice Bernstein, M.D. said...

I am not sure whether these "bloopers" are real or not, but whatever, they are representative of a host of real "mis-writing" that I wrote about in the tread "Medical Bloopers: A Medical Communication Defect" posted Dec. 12 2008 and which was as follows:


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.


SteveofCaley, I doubt bigotry is a factor in this discussion. Rather, all this is the result of the rush in the providing of profession medical care and we are left with amusing evidence of that rushing professional behavior. ..Maurice.


 

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