Dr. Maurice Bernstein, a teaching physician in California, has published a list of his favorite medical chart bloopers. Here it is:
1. The patient refused autopsy.
2. The patient has no previous history of suicides.
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.
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.
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.
18. She stated that she had been constipated for most of her life, until she got a divorce.
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.
Are there ethical ramifications for medical chart bloopers? You bet. Read Dr. Bernstein's comments here.