60+ Funny Charting Errors Found on Actual Medical Records

Charting at the end of a long shift is where grammar goes to die. You are rushing to finish before report, second-guessing whether it was Dilaudid or Dilaulid, and the sentence comes out sideways. Sometimes a charting slip means trouble. Sometimes it just means your coworkers will never let you live it down. Here are the ones worth saving.

Hilarious assessment cues

1. "Both breasts are equal and reactive to light and accommodation."
2. "Patient's chin cannot touch the table."
3. "Remnants of a soldier can be seen in the vagina."
4. "There is no noticeable difference in temperature between the legs."
5. "Patient has chest pain if she lies on her left side for over a year."
6. "Healthy appearing decrepit 69-year-old male, mentally alert but forgetful."
7. "She is numb from her toes down."
8. "The patient's feces has the same color as the doors on the 19th floor."
9. "On the second day the knee was better, and on the third day it disappeared."
10. "Cough with flame." (Apparently the patient was a dragon.)
11. "Rectal examination revealed a normal sized thyroid." (That is one long index finger.)
12. "Skin: somewhat pale but present."
13. "The skin was moist and dry."
14. "Occasional, constant, infrequent headaches."
15. "Patient was alert and unresponsive."
16. "By the time he was admitted, his rapid heart had stopped and he was feeling much better."
17. Assessing level of consciousness, a nurse charted: "easily aroused."

Weird yet funny patient history

18. "Patient lives at home with his mother, father, and pet turtle, who is presently enrolled in daycare three times a week."
19. "Many years ago the patient had frostbite of the right shoe."
20. "After quitting cigarette smoking, the patient started smelling again."
21. "The patient gets hives from contrasts, strawberries and shrimps and also two of her children."
22. "The patient had been depressed ever since she began seeing me in 1983."
23. "Patient had no past history of suicides."
24. "Patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex, which gradually deteriorated in the emergency room."
25. "The patient was in his usual state of good health until his airplane ran out of gas and crashed."
26. "She stated that she had been constipated for most of her life, until she got separated." (Talk about relief.)
27. "Patient has two teenage children, but no other abnormalities." (The DSM-V apparently now lists teenagers.)
28. "The patient was to have a bowel resection. However, he took a job as a stockbroker instead."
29. "He had a left-toe amputation one month ago. He also had a left-knee amputation last year."
30. "Patient lives with wife but works part-time in a whorehouse."

Hilarious nursing diagnoses

31. "Acute pain related to witchcraft."
32. "Bowel incontinence related to shyness."
33. "Insomnia related to computer games."

Out of this world interventions

34. "The baby was delivered, the cord clamped and cut, and handed to the pediatrician, who breathed and cried immediately."
35. "Patient received 5 mg of morphine for his pain in the ER."
36. "With O2 inhalation via foley bag catheter attached to urobag."
37. "Advised patient to take a bath."
38. "IVF consumed and terminated then replaced with the same IVF."
39. "Regulated IVF to KVO to run for 2 hours."
40. "While in the ER, she was examined, X-rated and sent home."
41. "The lab test indicated abnormal lover function."
42. "Pt. experiences frequent nausea and vomiting, and should therefore be wearing a small diaper at night."

Strange things nurses and patients say

43. "Patient refused an autopsy."
44. "Discharge status: alive but without permission."
45. "Patient has left his white blood cells at another hospital."
46. "Pt. is mildly agitated, but good in bed."
47. "Patient told me she lost her heart the last time she was admitted."
48. "She slipped on the ice and apparently her legs went in separate directions in early December."
49. "The patient had waffles for breakfast and anorexia for lunch."
50. "Patient eats death threats for breakfast."
51. "The patient has done well without oxygen for the past year."
52. "Patient continuing to jump out of bed, hasn't fallen, yet."

"Uhhhh?" doctor's orders

53. "Between you and me, we ought to be able to get this lady pregnant."
54. "Since she can't get pregnant with her husband, I thought you would like to work her up."
55. "Enteral tube feeding should be administered at 160 km per hour."
56. "Regarding the patient's impotence, we will continue his medication and let his wife see to the treatment."
57. "All visible brain tissue had been removed. The patient has no neurological complaints after surgery."
58. "Pt. is increasingly aggressive, but can be put down with a cup of coffee."
59. "Elevate balls between legs on 2 towels."
60. Written on an OB/Gyn chart: "f/u ck up." (It was meant to read follow-up checkup. The nurse was notified.)
61. "Return to ED for signs of infection: redness, fever, pu$$y drainage." (This was an arm laceration.)
62. "She has no rigors or shaking chills, but her husband states she was very hot in bed last night."