[The person who sent this list of hospital chart bloopers to the listserve for freelance medical writers I'm on said she couldn't vouch for the veracity of the list. But believe me, I've seen worse. I'm willing to bet these were actually entered on patients' charts. The comments in brackets are mine. Enjoy.]
HOSPITAL CHART BLOOPERS....
Actual writings from hospital charts:
1. The patient refused autopsy.
[My mother once called me and left a message saying that my sister-in-law's breast cancer surgery had gone well, my sister-in-law was doing fine, and they'd have the results of the autopsy in a couple of days.]
2. The patient has no previous history of suicides.
[Thank God for that. Hospitals need all the paying patients they can get.]
3. Patient has left white blood cells at another hospital.
4. She has no rigors or shaking chills, but her husband states she was very hot
in bed last night.
[Probably sprained something.]
5. Patient has chest pain if she lies on her left side for over a year.
6. On the second day the knee was better, and on the third day it disappeared.
7. The patient is tearful and crying constantly. She also appears to be depressed.
8. The patient has been depressed since she began seeing me in 1993.
[It's not me, Doc. It's you.]
9. Discharge status: Alive but without permission.
10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.
11. Patient had waffles for breakfast and anorexia for lunch.
12. She is numb from her toes down.
13. While in ER, she was examined, x-rated and sent home.
14. The skin was moist and dry.
15. Occasional, constant infrequent headaches.
16. Patient was alert and unresponsive.
17. Rectal examination revealed a normal size thyroid.
[Sure glad I wasn't the patient!]
18. She stated that she had been constipated for most of her life, until she got
[That's what happens when the guy you marry turns out to be an absolute s***.]
19. I saw your patient today, who is still under our car for physical therapy.
20. Both breasts are equal and reactive to light and accommodation.
21. Examination of genitalia reveals that he is circus sized.
22. The lab test indicated abnormal lover function.
23. Skin: somewhat pale but present.
24. The pelvic exam will be done later on the floor.
25. Patient has two teenage children, but no other abnormalities.
[I had that once. It seemed to last forever.]