Charting Blunders Submitted by our Web Site Visitors
Section Editor Kevin L. Smith, RNC, MSN, FNP

Medical Record Blunders

  1. Patient has a history of an atomic pregnancy. (as opposed to ectopic) — M. Bockerstette
  2. We will follow her eyes and nose with a foley catheter. — Jocelyn Ashton
  3. By the time he was admitted, his rapid heart had stopped, and he was feeling better. — NPInfo
  4. Patient has chest pain if she lies on her left side for over a year. — NPInfo
  5. On the second day the knee was better and on the third day it had completely disappeared. — NPInfo
  6. The patient has been depressed ever since she began seeing me in 1983. — NPInfo
  7. The patient is tearful and crying constantly. She also appears to be depressed. — NPInfo
  8. Discharge status: Alive but without permission. — NPInfo
  9. Healthy-appearing decrepit sixty-nine-year-old male, mentally alert but forgetful. — NPInfo
  10. The patient refused an autopsy. — NPInfo
  11. The patient expired on the floor uneventfully. — NPInfo
  12. Patient has left his white blood cells at another hospital. — NPInfo
  13. The patient's past medical history has been remarkably insignificant, with only a forty-pound weight gain in the past three days. — NPInfo
  14. She slipped on the ice and apparently her legs went in separate directions in early December. — NPInfo
  15. The patient had a rash over his truck. — Alicia Cook
  16. Dictation blunder: lasar radar response (as opposed to vagovagal response). — Alicia Cook
  17. On a medicare home care visit the nurse wrote, “upon arrival found patient in front yard raking leaves”. — Emily Giannattasio
  18. Patient’s catheter draining clear sputum — Heather Goodwin

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Updated February 5, 2008