Documentation

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Doc. errors 

z        ““Patient’s medical history has been remarkably insignificant with only a 40# weight gain in the past 3 months.”

z       

z        “Patient had waffles for breakfast and anorexia for lunch.”

Doc. errors 

z        “Skin somewhat pale but present.”

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z        “She is numb from her toes down.”

z       

z        “The patient was alert and unresponsive.”

Doc. errors

z        “The pelvic exam will be done later on the floor.”

z       

z        “Examination of genitalia reveals patient is circus sized.”

z       

z        “The nurse is to dress daily.”

Doc. errors

z        “The baby was discharged home after being given written and verbal instructions.”

Doc. errors 

z        “While in ER the patient was examined, X-rated and sent home”

z       

z        “Occasional, constant, infrequent headaches.”

Doc. errors 

z        “ Stated she had been constipated most of her life until she got a divorce.”

z       

z        “Both breasts are equal, reactive to light and accommodation.”

The Art of chart 

z        “ The baby was delivered, the cord clamped and cut and handed to the pediatrician, who breathed and cried immediately.”

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