The Best of Medical Chart Errors

After reviewing hundreds of medical charts over the course of my career in internal medicine, I can say with certainty that records often contain a great many errors, usually the result of less-than-perfect dictation or faulty copy and pasting.

Most of the errors are trivial, fortunately, and some can actually be quite humorous.

Here’s a sampling of some of these “doctor bloopers” I have heard about over the years:

• The baby was delivered, the cord clamped and cut, and handed to the pediatrician, who breathed and cried immediately.
• Rectal exam revealed a normal size thyroid. (Long fingers?)
• The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week.
• The patient was to have a bowel resection. However, he took a job as stockbroker instead.
• On the second day the knee was better and on the third day it had completely disappeared.
• Here is one I actually written about me. “The patient has been depressed ever since she began seeing Dr. Murray in 1983.”
• The patient will need disposition, and therefore we will get Dr. Murray to dispose of him.
• The patient's past medical history has been remarkably insignificant with only a 40-pound weight gain in the past 3 days.
• The patient experienced sudden onset of severe shortness of breath with acute pulmonary edema at home while having sex, which gradually deteriorated in the emergency room.
• The patient refused an autopsy.
• The patient left the hospital feeling much better except for her original complaints.
• She stated that she had been constipated for most of her life until 1989 when she got a divorce.
• Discharge status: Alive but without my permission.
• Since she can’t get pregnant with her husband, I thought you might like to work her up.
• The skin was moist and dry.
• Occasional, constant infrequent headaches. (Very through description.)
• We saw your patient today, who is still under our car for physical therapy.
• Large brown stool ambulating in the hall. (What?)
• Patient has 2 teenage children, but no other abnormalities.

You really can’t make this stuff up. You just have to laugh. Happy New Year to everyone!

If you know of any other funny chart entries, we’d like to know. Send an email to Smurray@mjhassoc.com.