What Did You Really Mean to Say in that Medical Record?

Often our jobs as Hospitalists and Emergency Medicine physicians are to create and manage a medical record that is meaningful. With that in mind, the following are sentences extracted from patient records exactly as typed by medical secretaries in the N.H.S. (National Health Service – Greater Glasgow). The N.H.S. is the largest health board in the United Kingdom, providing healthcare to over 1.2 million people and employing more than 40,000 staff members.

1. The patient has no previous history of suicide.
2. Patient has left her white blood cells at another hospital.
3. Patient’s medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.
4. She has no rigors or shaking chills, but her husband states she was very hot in bed last night.
5. Patient has chest pain if she lies on her left side for over a year.
6. On the second day the knee was better and on the third day it disappeared.
7. Discharge status: Alive, but without my permission.
8. Healthy appearing decrepit 69- year old male, mentally alert, but forgetful.
9. Patient had waffles for breakfast and anorexia for lunch.
10. She is numb from her toes down.
11. While in A&E, she was examined, X-rated and sent home.
12. The skin was moist and dry.
13. Occasional, constant infrequent headaches.
14. Patient was alert and unresponsive.
15. Rectal examination revealed a normal size thyroid.
16. She stated that she had been constipated for most of her life until she got a divorce.
17. Both breasts are equal and reactive to light and accommodation.
18. Examination of genitalia reveals that he is circus sized.
19. The lab test indicated abnormal lover function.
20. Skin: somewhat pale, but present.
21. Large brown stool ambulating in the hall.
22. Patient has two teenage children, but no other abnormalities.
23. When she fainted, her eyes rolled around the room.
24. The patient was in his usual state of good health until his airplane ran out of fuel and crashed.
25. Between you and me, we ought to be able to get this lady pregnant.
26. Patient was seen in consultation by Dr. Smith, who felt we should sit on the abdomen and I agree.
27. The patient was to have a bowel resection. However, he took a job as a stock broker instead.

So, let’s just presume I made this whole thing up. Still we have all likely read things in others medical records that are nearly as outrageous as these statements. It is ideal, within the functionality of a medical record to “paint a picture of your patient in time.” This allows for an accurate, reliable and complete record that can be referred to and translated by any professional needing to make good decisions about the patient they are evaluating using the information within the records provided. What can we take away from these invaluable misquotations?

These statements are not particularly defensible in a court of law, and they fail to document the details that may make the difference between credibility and laughability. Undeniably, “Dictated but not read” can be a recipe for a medical record disaster that may find its way to a viral internet publication!