[Sazerac]

Some Medical Records bloopers (my mom used to work in Medical Records for a hospital; I still have some of these around!) These were taken from actual patients' files and doctor's dictations. NOTE: making proofreading mistakes for medical records may cost someone their life when it comes to medications or diagnoses. These are funny, but not all mistakes are!


Looking up the patient's rectum was fine.

The patient has been up and around the halls this morning having BM's.

Both the patient and the nurse reported feeling better after having had an enema.

The patient was found dead in bed after an otherwise good day.

The patient was diagnosed with a cute appendicitis.

Bleeding started in the rectal area and continued all the way to New Orleans.

When the patient fainted, her eyes rolled around the room.

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

The patient has been depressed ever since seeing me in 1995.

The patient refused an autopsy.

Patient has had no past history of suicides.

The patient's white blood cells were left at another hospital.

Since she can't get pregnant by her husband, I thought you would like to work her up.

She is numb from her toes down.

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

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 had been constipated for most of her life until 1998 when she got a divorce.

The patient had waffles for breakfast and anorexia for lunch.

Examination of the patient's genitalia revealed that he is circus sized.

The patient was in his usual state of good health until he lost control of his car and it crashed.

Between you and me, we ought to be able to get this lady pregnant.

The lab tests indicate an abnormal lover function.

While in the emergency room he was examined, X-rated, and sent home.

Patient was alert, and unresponsive.

Both the patient and the nurse herself reported passing flatus.

On the second day, the knee was better and by the third day it had completely disappeared.

She had a miscarriage at the age of four months.

The patient's head was in neutral.

The left leg became numb at times and he walked it off.

Husband also reports severe menstrual bleeding the past two periods.

Discharge status: alive but with permission.

This fourteen-year-old boy argued with a lawnmower, who then attacked him.

Patient was a great white male.

Patient states she was bitten by both legs of a dog.

She slipped on the ice and apparently her legs went in opposite directions in early December.

Patient was in her usual state of good health when she felt her toilet in her back.

Patient was admitted to the hospital on the date of her admission.

Patient was seen about four weeks ago by a physician with a urethral drip.

Coming from Shreveport, this man has no children.

The patient is a 71-year-old female who fractured her finger while beating up a cake.

Physician has been following the patient's breasts for about 6 years now.

Patient is a real gas factory.

Patient had onset of severe Sunday evening.

Patient has chest pain if she lies on her left side for over a year.

Skin: somewhat pale but present.

Large brown stool seen ambulating in hall.

Vaginal packing out. Dr. in.

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