"Excuse me, did you mean to chart this?"
Section Editor Kevin L. Smith, RNC, MSN, FNP
Medical Record Blunders
- The lab test indicated abnormal lover function.
- The baby was delivered, the cord clamped and cut, and handed to the pediatrician, who breathed and cried immediately.
- Exam of genitalia reveals that he is circus sized.
- The skin was moist and dry.
- Rectal exam revealed a normal size thyroid. (Long fingers?)
- 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.
- Between you and me, we ought to be able to get this lady pregnant.
- The patient was in his usual state of good health until his airplane ran out of gas and crashed.
- I saw your patient today, who is still under our car for physical therapy.
- The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week.
- Bleeding started in the rectal area and continued all the way to Los Angeles.
- Both breasts are equal and reactive to light and accommodation. (Excuse me, what are you doing with that pen light?)
- She is numb from her toes down.
- Exam of genitalia was completely negative except for the right foot. (Anatomy review time!)
- While in the emergency room, she was examined, X-rated and sent home.
- The patient was to have a bowel resection. However, he took a job as a stockbroker instead. (An empowered patient.)
- The patient suffers from occasional, constant, infrequent headaches.
- Coming from Detroit, this man has no children.
- Examination reveals a well-developed male lying in bed with his family in no distress.
- Patient was alert and unresponsive.
- When she fainted, her eyes rolled around the room.
Submit Your Own Charting Blunders!