"Do you know what my most important tool is?" he asked.
I thought for a minute. "Your stethoscope?" It seemed a logical answer.
"No, my pen," he responded.
Insurance paperwork to fill out, prescriptions to write, and probably most of all, the infamous charting. Everything you do and observe as a physician is supposed to go in a patient's chart. As I have seen at the free clinic where I work, this can take quite a while and be a very detail-oriented task, especially if there are multiple issues going on with the patient.
Here I present some examples of medical charting gone wrong, courtesy of an e-mail from my mom. I hope to post more humorous pieces like this in the future, because as the saying goes, "Laughter is the best medicine." Enjoy!
Hospital Chart Bloopers
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. Note: patient here -- recovering from forehead cut. Patient became very angry when given an enema by mistake.
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. Examination of genitalia reveals that he is circus sized.
21. The lab test indicated abnormal lover function.
22. Skin: somewhat pale but present.
23. Patient has two teenage children, but no other abnormalities.