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Charting Chuckles

At one time or another, every health care professional has
probably charted a note or two that didn't come out quite right.
These bloopers were collected from medical records across the country.



Cardiac

  • Patient has chest pains if she lies on her left side for over a year.

  • By the time she was admitted to the hospital, her rapid heart had stopped and she was feeling much better.

Musculoskeletal

  • On the second day, the knee was better, and on the third day, it had completely disappeared.

  • While in the emergency department she was examined, X-rated, and sent home.

Neurologic

  • Patient was alert and unresponsive.

  • Healthy appearing, decrepit 69-year-old female, mentally alert, but forgetful.

  • She is numb from her toes down.

  • When she fainted, her eyes rolled around the room.

Gastrointestinal

  • Rectal examination revealed a normal-size thyroid.

  • The patient had waffles for breakfast and anorexia for lunch.

  • She stated that she had been constipated for most of her life until 1989, when she got a divorce.

  • Bleeding started in the rectal area and continued all the way to Los Angeles.

  • The patient was to have a bowel resection. However, he took a job as a stockbroker instead.

  • Fleet enema given with stool hard as pine knots.

  • Patient complains of indigestion since last night when he ate a stake.

  • Patient passed flatus . . . two short, one long.

  • Patient was seen in consultation by the physician, who felt we should sit tight on the abdomen, and I agreed.

Gynecologic/Urologic

  • Examination of genitalia reveals that he is circus-sized.

  • Indwelling urinary catheter draining clear yellow roses.

  • Examination of genitalia was completely negative except for the right foot.

  • Pelvic examination to be done later on the floor.

  • Indwelling urinary catheter draining large amount of urine the color of American beer.

  • M.D. at bedside attempting to urinate. Unsuccessful.
    (The physician was actually attempting to intubate).

Social History

  • The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week.

  • Patient was in his usual state of good health until his airplane ran out of gas and crashed.

  • Examination reveals a well-developed male lying in bed with his family in no distress.

Miscellaneous

  • The skin was moist and dry.

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

  • The baby was delivered; the cord, clamped and cut and handed to the pediatrician, who breathed and cried immediately.

  • Skin: somewhat pale, but present.

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

  • Because she can't get pregnant with her husband, I thought you'd like to work her up.

  • The test indicated abnormal lover function.

  • If he squeezes the back of his neck for 4 or 5 years, it comes and goes.

  • Discharge status: alive, but without permission.

~December Issue, Nursing 97~




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