Medical Record Blunders

1.

The skin was moist and dry.
2.

Rectal exam revealed a normal size thyroid. (Long fingers?)
3.

The patient had waffles for breakfast and anorexia for lunch.
4.

She stated that she had been constipated for most of her life until 1989 when she got a divorce.
5.

Between you and me, we ought to be able to get this lady pregnant.
6.

The patient was in his usual state of good health until his airplane ran out of gas and crashed.
7.

The lab test indicated abnormal lover function.
8.

The baby was delivered, the cord clamped and cut, and handed to the pediatrician, who breathed and cried immediately.
9.

Exam of genitalia reveals that he is circus sized.
10.

I saw your patient today, who is still under our car for physical therapy.
11.

The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week.
12.

Bleeding started in the rectal area and continued all the way to Los Angeles.
13.

Both breasts are equal and reactive to light and accommodation. (Excuse me, what are you doing with that pen light?)
14.

She is numb from her toes down.
15.

Exam of genitalia was completely negative except for the right foot. (Anatomy review time!)
16.

While in the emergency room, she was examined, X-rated and sent home.
17.

The patient was to have a bowel resection. However, he took a job as a stockbroker instead. (An empowered patient.)
18.

The patient suffers from occasional, constant, infrequent headaches.
19.

Coming from Detroit, this man has no children.
20.

Examination reveals a well-developed male lying in bed with his family in no distress.
21.

Patient was alert and unresponsive.
22.

When she fainted, her eyes rolled around the room.
23.

We will follow her eyes and nose with a foley catheter.
24.

By the time he was admitted, his rapid heart had stopped, and he was feeling better.
25.

Patient has chest pain if she lies on her left side for over a year.
26.

On the second day the knee was better and on the third day it had completely disappeared.
27.

The patient has been depressed ever since she began seeing me in 1983.
28.

The patient is tearful and crying constantly. She also appears to be depressed.
29.

Discharge status: Alive but without permission.
30.

Healthy-appearing decrepit sixty-nine-year-old male, mentally alert but forgetful.
31.

The patient refused an autopsy.
32.

The patient expired on the floor uneventfully.
33.

Patient has left his white blood cells at another hospital.
34.

The patient's past medical history has been remarkably insignificant, with only a forty-pound weight gain in the past three days.
35.

She slipped on the ice and apparently her legs went in separate directions in early December.
36.

The patient had a rash over his truck.
37.

Dictation blunder: lasar radar response (as opposed to vagovagal response).