Tuesday, March 04, 2008

watch what you write

In the medical world, charting and documentation dominates.

From a legal standpoint, proper charting could save your but if you go to get sued, improper/sloppy/half asses charting pretty much asks the plaintiff" How much is this going to cost me?"

From a medical standpoint, the entire point of charting is to be communicative and objective to the rest of the medical team, i.e. make sure everyone is on the same page with access to the same information to make informed decisisons regarding patient care.

We are all guilty of some type of "bad charting" (oh God, I am the QUEEN of spelling errors), but here are a few examples of what you don't want to be caught charting (unless, that is, you enjoy being laughed at by your co-workers/everyone who reads this blog entry/anyone who read the original posting....

*ACTUAL SENTENCES FOUND IN PATIENTS 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. Patent'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. Between you and me, we ought to be able to get this lady pregnant.

14. Since she can't get pregnant with her husband, I thought you might like to
work her up.

15. She is numb from her toes down.

16. While in ER, she was examined, X-rated and sent home.

17. The skin was moist and dry.

18. Occasional, constant infrequent headaches.

19. Patient was alert and unresponsive.

20. Rectal examination revealed a normal size thyroid.

21. She stated that she had been constipated for most of her life, until she got
a divorce.

22. I saw your patient today, who is still under our car for physical therapy.

23. Both breasts are equal and reactive to light and accommodation.

24. Examination of genitalia reveals that he is circus sized.

25. The lab test indicated abnormal lover function.

26. The patient was to have a bowel resection. However, he took a job as a stock
broker instead.

27. Skin: somewhat pale but present.

28. The pelvic exam will be done later on the floor.

29. Patient was seen in consultation by Dr. Blank, who felt we should sit on the
abdomen and I agree.

30. Large brown stool ambulating in the hall.

31. Patient has two teenage children, but no other abnormalities.


Hope this made you smile. Now, type on fellow bloggers, type on! (utilizing spell check of course!)

1 comment:

valmg said...

As I do billing and coding I work with ambulance trip sheets every day and I agree, poor choice of words makes for humorous reading, as does questionable penmanship at times.