Medical Charting Bloopers

These are actual entries made in hospital charts:

1. She has no rigors or shaking chills, but her husband states she was very hot in bed last night.
2. Patient has chest pain if she lies on her left side for over a year.
3. On the second day the knee was better, and on the third day it disappeared.
4. The patient is tearful and crying constantly. She also appears to be depressed.
5. The patient has been depressed since she began seeing me in 1993.
6. Discharge status: Alive but without my permission.
7. Healthy appearing decrepit 69-year-old male, mentally alert but forgetful.
8. The patient refused autopsy.
9. The patient has no previous history of suicides.
10. Patient has left white blood cells at another hospital.
11. Patient's medical history has been remarkably insignificant with only a 40-pound weight gain in the past three days.
12. Patient had waffles for breakfast and anorexia for lunch.
13. She is numb from her toes down.
14. While in ER, she was examined, x-rated and sent home.
15. The skin was moist and dry.
16. Occasional constant infrequent headaches.
17. Patient was alert and unresponsive.
18. Rectal examination revealed a normal-size thyroid.
19. She stated that she had been constipated for most of her life, until she got a divorce.
20. I saw your patient today, who is still under our car for physical therapy.
21. Both breasts are equal and reactive to light and accommodation.
22. Examination of genitalia reveals that he is circus sized.
23. The lab test indicated abnormal lover function.
24. The patient was to have a bowel resection. However, he took a job as a stockbroker instead.
25. Skin: somewhat pale but present.
26. The pelvic exam will be done later on the floor.
27. Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen, and I agree.
28. Large brown stool ambulating in the hall.
29. Patient has two teenage children but no other abnormalities.
30. Between you and me, we ought to be able to get this lady pregnant.
31. "Bleeding began in the rectal area and continued all the way to Los Angeles."
32. "Patient came in today complaining of chronic vaginal affection."
33. "Since she can't conceive I've sent her to a futility expert."
34. "Surgery will be performed under General Anastasia."
35. "I've asked him to call and let me know who he's feeling this week."
36. "There was some concern about financial matters, but the patient was told she could apply for pubic assistance."
37. "After her last child she had her tubs tied."
38. "Infection resulted after she pimped a few popples."
39. "Social history reveals this 1 year old patient does not smoke or drink and is presently unemployed."
40. "Patient called and left word that he had expired last week."
41. "When she fainted her eyes rolled around the room."
42. "Prior to surgery she was prepped and raped in the usual fashion."
43. "He's rather sedentary and drives a bust all day."
44. "This chubby youngster needs a slim adult to look up to as a role model."
45. "Both her old and new noses have been placed in our album."
46. "I keep reassuring her that her memory will improve, but again today she forgot to pay her bill."
47. "I told her that for the time being she'll have to bare with me."
48. "His prognosis was poor, having a massive cerebral hemorrhoid."
49. "He's a ten month old male who called on the day of admission to complain that his asthma was worse and he still has left otitis media."
50. "Patient is to remain plastered for the next 6 to 8 weeks."
51. "She got my instructions messed up and cut out all exercise and increased her sweets."
52. "Following the exam of her breasts we discussed the impending nasal surgery."
53. Since she can't get pregnant with her husband, I thought you might like to work her up.
54. The dermatologist made a recommendation for treatment of her face which is not of a serious nature.
55. He was eating his tray so I didn't examine him.
56. I will be happy to go into her GI system, she seems ready and anxious.
57. The patient's bladder was then emptied and sent to the postoperative recovery room in stable condition.
58. The bugs that grew out of her urine were cultured in the Casualty and are not available. I WILL FIND THEM!!!
59. May have lollipops orally.
60. Discontinue precious insulin orders.
61. Further suggested that she avoid using toilet paper and use cotton underwear.
62. He was advised to force fluids through his interpreter.
63. She can begin to use the lawn mower, but no vaginal entrance.
64. She is to refrain from sexual intercourse until I see her in the office.
65. For his impotence we will discontinue the meds and let his wife handle him.
66. I have suggested that he loosen his pants before standing, and then, when he stands with the help of his wife, they should fall to the floor.
67. The patient will need disposition, and therefore we will get Dr. Blank to dispose of him.
68. MD order: Dulcolax suppository po prn
69. MD order: May shower with nurse
70. The patient has difficulty swallowing pillows and has to turn her head to one side.
71. No mobility limitations noted except for difficulty with transfers, standing, turning and ambulating. (What’s left?)
72. Observed by nurses in bed.
73. The patient was lying flat on a guernsey. (British Channel Island of Guernsey).
74. Patient was asked to breathe but she refused.
75. The patient was wondering in the parking loft and fell from the sidewalk.
76. (Patient found dead): Felt cold, blanket added, voiced no complaints.
77. The baby was delivered, the cord clamped and cut, and handed to the pediatrician, who breathed and cried immediately.
78. Met patient in bed at 3 PM.
79. Discharge status: alive but without permission.
80. The patient left the hospital feeling much better except for her original complaints.
81. He had a left-toe amputation one month ago. He also had a left-knee amputation last year.
82. Patient was released to outpatient department without dressing.
83. The patient expired on the floor uneventfully.
84. Patient discharged with prescription on foot.
85. Patient seen in the floor.
86. Examination reveals a well-developed male lying in bed with his family in no distress.
87. Skin intact, red, and broken
88. Pulses are probably in both feet.
89. The rest of the physical examination is normal, including the right hands.
90. The genitalia are normal in experience... I'm sorry... appearance.
91. Description of hemorrhoids: "Big Time"
92. Respirations deep and regular--no breath sounds.
93. Abdomen soft, no liver or spleen (ed: you can't live without a liver)
94. Exam of genitalia was completely negative except for the right foot.
95. Since the patient stopped smoking, his smell is beginning to return.
96. She was unresponsive but still bleeding spontaneously.
97. Stool remains quite spry and active.
98. My arm is fractured but not broken
99. I’m having gas pains in my head.
100. I’m not constipated; I can breathe just fine.