Date: Wed, 12 Jul 1995 07:43:19 -0400 (EDT) Subject: BLAGUES-L: Doctors' Chart Bloopers Hi guys, I know everyone has received wrong number phone calls before, but today I received my first wrong fax. The first page had a smiley face with girls long hair on it and it said "Hi Dawn. We miss you, Please empty your bladder before reading guess who?" Well, I didn't try to "guess who" but I did read the following page and it was hilarious :-). I hope they eventually did get it to Dawn... Well, anyway, here it is: Charting Bloopers Adele D.S. Mitchell, PhD, RN I know that we are often in a hurry and mistakes happen, but I'm amazed by how some people chart. I've been collecting chart bloopers by physicians and nurses for years. The following were found in a variety of places; some may have come from your institution. Can you imagine what would happen if these notes appeared in court? 1. Patient has chest pain if she lies on her left side for over a year. 2. On the second day the knee was better and on the third day it had completely disappeared. 3. Father died in his 90's of female trouble in his prostate and kidneys. 4. Skin: Somewhat pale but present. 5. The pelvic examination will be done later on the floor. 6. Vomiting of unknown origin. 7. New onset chronic comma. 8. Admitted in error. 9. Evaluate for progressive ambulation. 10. Diagnosis: Gunshot wound to the head, coma. 11. Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen and I agree. 12. Large brown stool ambulating in the hall. 13. Patient has two teenage children but no other abnormalities. 14. B-9 Position vertigo. 15. Discharge status: Alive but without permission. 16. Vaginal packing out. Doctor in. 17. Dr. Blank is watching his prostate. 18. Patient had bilateral varicosities below the legs. 19. If he squeezes the back of his neck for 4 or 5 years it comes and goes. 20. At the time of onset of pregnancy, the mother was undergoing bronchoscopy. 21. She was treated with Mycostatin oral suppositories. 22. Healthy appearing decrepit 69 year old white female, mentally alert but forgetful. 23. 1 Benign chest removed from the pelvis. 24. Large amount of brown feces expelled. Well, there you have 'em. I hope you enjoyed them as much as I did. Catch ya' later. Sincerely, Aaron J. Samuelson