De-identified Humorous Examples of Actual Medical Records

By Jeff Ribordy, MD, MPH, FAAP, Regional Medical Director

Back in 2018 we published a mildly humorous blog post highlighting medical bloopers that we have encountered as we peruse the chart notes we receive. Of course back then, EHRs were so new that most providers were still getting used to working with them. Nowadays, everyone is such an expert we rarely see charting mistakes…..

Just kidding!

Here is our long awaited sequel with upgraded oopsies – just like the EHRs we all use.

As we share these I want to mention as in the previous post – this is not to point fingers but with the understanding we all have made similar mistakes.

From the “Not Sure That’s How That Works” Department

–…he sleeps flat with 8 pillows <…>

–She lifts boxes which way 5200 pounds all day long while working in a warehouse.

–General: Pt is awake, alert and oriented. No acute distress. Husband present. PT is ambulating in a wheelchair.

–Born as full term at 51 weeks, no major complication reported during delivery.

–Allergies: CARBOHYDRATE

–He was twin B (5 lb 11) needed chest compression for 3 days. Not intubated.

–Is a 56-year-old male – Alcohol: Currently does not drink; but did drink a sixpack of beer per day for 78 years.

–Sister states that patient carries a diagnosis of schizophrenia but patient refused to take medication. Main symptoms of her schizophrenia was shyness and not talking to others.

–Patient states she believes she has MS. She states she did some online research and wants to be tested for MS. When asked what sx she is currently having in regards to MS, Pt asked, “Can I have a phone to look up the symptoms of MS.”

–Ms. M… had a sudden loss of both eyes that occurred in December 2018.

Might Need Another Treatment Plan…

–If the injection helps, then consider radio frequency abrasion.

–He was diluted with x-rays and sent home.

–Prognosis for controlling incontinence: Hyperlipidemia

–Discussed – Unfortunately kidney has failed to have any benefit from an L4 transforaminal epidural steroid injection.

–PLAN – Hyperlipidemia, unspecified, TraMADol HCI 50 MG tablet, 1 every 4-6 hours as needed, 30 days, 0 refills.

–Methamphetamine abuse  F15.10 – The patient appears interested in taking this habit.

Kid’s Doctors Say the Darnedest Things…

–3yo daughter Callie, works as a cashier

–SOCIAL HISTORY: The patient is in the fourth grade, denies use of alcohol and tobacco.

–10 year old female here with a chief complaint of eating.

–Please let mom know Xray from last week shows moderate poop.

Captain, the Universal Translator is malfunctioning…

–Ongoing tobacco use: Advised to quit yet another gallops left left knee surgery on their printer milligrams daily.

–Reminder of value of glucose level w/level of pain & why.

–Plan: Patient with hypoplastic left heart status post Norwood procedure N salmonella shunt mother with excellent Binder for following medical home we’ll need to clarify dosages of medications.

From The MD who was an undergrad Philosophy Major…

–The symptoms occur.

And more good advice for everyone:

–She married a drug dealer which she advises not to ever marry a drug dealer.

 

 

 

 

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