|
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~
|