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Tuesday, June 14, 2011

HOSPITAL CHART BLOOPERS

(Actual writings from hospital charts)
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> 1 . The patient refused autopsy.
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> 2. The patient has no previous history of suicides.
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> 3. Patient has left white blood cells at another hospital.
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> 4. She has no rigors or shaking chills, but her husband states she was very hot in bed last night.
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> 5. Patient has chest pain if she lies on her left side for over a year.
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> 6. On the second day the knee was better and on the third day it disappeared.
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> 7. The patient is tearful and crying constantly. She also appears to be depressed.
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> 8 The patient has been depressed since she began seeing me in 1993.
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> 9. Discharge status: Alive but without permission.
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> 10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.
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> 11. Patient had waffles for breakfast and anorexia for lunch.
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> 12. She is numb from her toes down.
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> 13. While in ER, she was examined, x-rated and sent home.
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> 14. The skin was moist and dry.
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> 15. Occasional, constant infrequent headaches.
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> 16. Patient was alert and unresponsive.
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> 17. Rectal examination revealed a normal size thyroid.
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> 18. She stated that she had been constipated for most of her life, until she got a divorce.
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> 19. I saw your patient today, who is still under our car for physical therapy.
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> 20. Both breasts are equal and reactive to light and accommodation.
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> 21. Examination of genitalia reveals that he is circus sized.
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> 22 The lab test indicated abnormal lover function.
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> 23. Skin: somewhat pale but present.
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> 24. The pelvic exam will be done later on the floor.
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> 25. Patient has two teenage children, but no other abnormalities.



26. vomiting one week ago containing foot particle

27. right iliac fossa pain not aggravated by foot

i encountered no. 26 and 27 myself in a medical record at a hospital where i did my practical...huhu


p/s: a reminder for my by my dearest lecturer: mr ahmed awil adam..(desperately praying that i won't do the same mistake and to constantly check my English as a medical document is a legal document and my words can be used against me..yikes)

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