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Misplaced Modifiers

Old 06-01-2010, 08:55 AM
  #1  
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Default Misplaced Modifiers

HOSPITAL CHART BLOOPERS
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>> (Actual writings from hospital charts)
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>> 1. The patient refused autopsy.
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>> 2. The patient has no history of suicides.
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>> 3. Patient has left white blood cells at another hospital.
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>> 4. She has no rigors or shaking chills, but her husband states she was very hot in bed last night.
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>> 5. Patient has chest pain if she lies on her left side for over a year.
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>> 6. On the second day the knee was better and on the third day it disappeared.
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>> 7. The patient is tearful and crying constantly. She also appears to be depressed.
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>> 8. The patient has been depressed since she began seeing me in 1993.
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>> 9. Discharge status: Alive but without permission.
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>> 10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.
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>> 11. Patient had waffles for breakfast and anorexia for lunch.
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>> 12. She is numb from her toes down.
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>> 13. While in ER, she was examined, x-rated and sent home.
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>> 14. The skin was moist and dry.
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>> 15. Occasional, constant infrequent headaches.
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>> 16. Patient was alert and unresponsive.
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>> 17. Rectal examination revealed a normal size thyroid.
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>> 18. She stated that she had been constipated for most of her life, until she got a divorce.
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>> 19. I saw your patient today, who is still under our car for physical therapy.
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>> 20. Both breasts are equal and reactive to light and accommodation.
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>> 21. Examination of genitalia reveals that he is circus sized.
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>> 22. The lab test indicated abnormal lover function.
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>> 23. Skin: somewhat pale but present.
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>> 24. The pelvic exam will be done later on the floor.
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>> 25. Patient has two teenage children, but no other abnormalities.
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>> -------------
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Old 06-03-2010, 09:05 PM
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This is EXACTLY why you must read every dictation you do these days! I have seen some similar stuff come back in my dictations, and I am positive I never said what was in that document. You simply wouldn't say stuff like these lines when dictating:

Examination of genitalia reveals that he is circus sized.

or

The lab test indicated abnormal lover function.

But those things can easily get transcribed. It sure seems to me that they find transcriptionists with less and less experience all the time. When you get a couple of them trained as to the way you typically say and phrase things and can relax a bit on reviewing the dictation, they move on. Then have to start all over again, and train the next batch. What scares me is that many docs don't bother to read their dictations line-by-line, and this stuff makes it into the chart in a *signed* note! Good luck with that if there's ever a law suit...

TB
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Old 06-03-2010, 09:49 PM
  #3  
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O/T Response
Getting a prescription the pharmacist assistant asked if I had any allergies.....my response was yeah to rich single women....she excused herself and the cashier and laughed their asses off behind the wall, she came back in smiles tears and apologies and asked seriously???
A funny moment shared between us...
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Old 06-04-2010, 07:34 AM
  #4  
CJS
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17. Rectal examination revealed a normal size thyroid.

Talk about look at something from a different point of view
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Old 06-05-2010, 05:27 AM
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That's what happens when you outsource dictation notes to China....
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