Unintended Humor: Bad Chart Writing

Physicians learn in medical school to take a careful and complete history and perform a thorough physical exam. But this is only one aspect of what physicians do. The other part is actually writing down what information they obtained. And this is when mistakes can occur.. not necessarily on purpose. The mistakes occur because many physicians really don’t understand grammar (how to write) or they are just plain rushed or tired. Doctors should be reminded to read what they just wrote and ask themselves: “Is this what I really wanted to say?”
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What you see below are examples of such writing. The physician is trying to express something important and real but unfortunately how it is expressed is grossly misleading and often, as seen in these examples, humorous. Anyone have any other examples? ..Maurice.

EXAMPLES OF BAD CHART WRITING

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. She has no rigors or shaking chills, but her husband states she was very
hot in bed last night.

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 my 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.