If you've been here hanging around long enough, you know I do (or did) medical transcription from home, I used to type for the longest time, and then I did quality assurance of other MTs reports; however as of March 2010, I have been in management! Lord have mercy...I know...its a whole new world! Here is some of the crazy stuff I encounter...(be warned I am sort of a grammar nazi but only when it comes to the health records I have to read and fix!)
While reading through reports in QA, "She can lift a picture of Kool-Aid" ... haha! You're kidding me? a picture? I can't believe somebody would leave that in a report. If I remember correctly that Kool-Aid pitcher guy was pretty hefty!
Hefty! Hefty! Hefty! (straight off commercial TV...ya know you wanted to say that!)
in QA today, "her husband is an insurance jester!" (gives a whole new meaning don't you think?)
One of my all-times favs..."the patient went to "alimentary school" ? hahaha ... You think that's bad ..."The client was dressed in genes and a T-shirt..." just a few crackups in my (Mon)day!
The patient was born in Maine, West Virginia...(You're kidding, right? surely you looked that up? No? figures...it should be Man, WV)
"The patient worked at the Jacquar for 12 years?" I'm thinking a strip club? nah, the doctor dictated "The patient worked at the Job Corps!" hahaha
more WTF transcriptionist errors...
"She is recovering attic and alcoholic. " and if that wasn't bad enough in just a few sentences later, "She just recently completed a third age test." (that was AIDS test). Duh! Do these MT's not realize this makes absolutely no sentence sense? uh...gave me a good laugh though at the same time a little concern.
"There are times I have to make myself maid." (yeah, doctor said bathe...ok, we understand you're depressed..ugh..ick)
She has never severed in the military. (oops! and if she doesn't stop making such stupid typos she might get severed herself! lol..)
or this lovely one..."He was shotted in the left side of his back." (uh...okay I don't think there is such a word, do you? haha)
the doctor slurs, "The patient has six siblings living in a well...?
duh! big red truck! should be ... living and well!
..."patient suffers from hemineglect?" I don't know about yuns but I'm feeling a little neglected myself! This is a real diagnosis by the way which I did a post on.
recent blurb, patient states, "I fell off the short bus and got run over by the bus driver!"
"Mrs. So-And-So's hobby is cropping." At least that's what the transcriptionist typed...LOL ...but it should have been quilting?! I do not know how they come up with some of the stuff they type!
The patient has blonde hair and is alive! duh (I should hope so!)...that should have been "The patient has blonde hair and hazel eyes!"
and my fav at the moment..."this charge was dropped Mr. Meaner." ...did you mean to a misdemeanor?! hahaha!
Doctor says...
(and I typed)... "The patient worked for a year doing "out of body?" huh? oh yeah, that should be autobody! ha!
"She smokes two to three cups of coffee per day, and consumes four caffeinated soft drinks per day..."
"His drawers appears to be normal."
These doctors are source of amusement on an given day! and now that I am doing QA, the MTs (medical transcriptionists) can type some funny crazy stuff, too!
Here is my funny boo-boo this morning while trying to carry on a conversation and type at the same time ...
DISPOSITION: He is discharged home in stable condition. Follow up in 10 days for future removal.
uhhh ... I mean suture removal! ha!
Dr. O stated, "the patient has stool in his blood?"
Shamie, you know that ain't right!
and then there is Dr. Klineisms ...
here's a Klinism ... lol ...She fits into the category of “warm and dry” at this stage.
I'm thinking as opposed to what? wet and drippy?
He has such a lovely way of putting things too ... such as describing patients ...
like this ...
The patient is a hypertensive, obese, dyslipidemic diabetic, and realizes that control of glucose has been poor.
but at least he didn't call her a lass!
The wound measures about 3 centimeters in the long axis of the thenar eminence and about 1 centimeter orthogonally.
What is wrong with this report, folks???
HISTORY OF CHIEF COMPLAINT: Ms. XXXX is a 23-year-old female who comes into the emergency room by ambulance after alleging taking seven 5/500 Lortab and drinking alcohol at about 5:30 this morning. The patient does not admit to any suicidal ideation, does not have any pain complaints.
PAST MEDICAL HISTORY: Noncontributory.
SOCIAL HISTORY: Positive alcohol. Denies substance abuse.
REVIEW OF SYSTEMS: Negative except as items stated above.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.6, pulse 103, respirations 18, blood pressure 136/71, and pulse oximetry 100% on room air.
GENERAL: The patient is alert and oriented x3, has a flat affect with intermittent tearing. The patient does not admit to suicidal ideations, and does not admit to any homicidal ideation. No evidence of self-mutilation noted.
HEENT: Head is atraumatic. Pupils are equal and reactive to light and accommodation. There is no obstruction or stridor. No cervical adenopathy.
BREAST EXAM: Negative. (what would a breast exam reveal on a suicidal patient? seriously)
NECK: There is no meningismus.
NECK: There is no meningismus.
HEART: Heart rate and rhythm are regular without murmur, rubs, or clicks.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Bowel sounds are positive. There is no rebound or guarding and no pulsatile masses.
EXTREMITIES: Full range of motion.
NEUROLOGICAL: There are no focal neurological deficits.
DIAGNOSTIC STUDIES / LABS: Tylenol level at 4 hours is 40 mcg/cc. The Tylenol level that was drawn at two hours is 64 mcg/cc. Chemistry panel showed sodium of 143, potassium 4.0, chloride 112, bicarb 24, BUN 10, creatinine 0.8, glucose 127, AST 28, ALT 21, alk phos is 50. Ethanol level at 07:49 was 200. Salicylate level is less than 4. Urine drug screen is positive for benzodiazepines and opiates. Hemoglobin 14.7, white count 6,000, platelets are 347.
EMERGENCY DEPARTMENT COURSE: A Behavioral Medicine consult was requested. Behavioral Medicine evaluated the patient and is low risk for suicidal. The patient has been instructed by Behavioral Medicine to follow up for individual counseling.
IMPRESSION: Depression, substance abuse.
PLAN: Follow up as Behavioral Medicine requested.
Reexamination at 08:26 shows that he is able to move smoothly from a
reclining to sitting, to a standing position, and to perform full
<_____tworks?_________> of the entire spine without limitation or
hesitation. (torques)
Anal wink is present. ? Yep, betcha didn't know your ass could wink didya?
If you're looking for more transcription laughs...try checking out these posts...If you have a job that tries to take over your sanity, remember...tomorrow's a new day! another chance to screw up! LOL
Open Mouth...Insert Scream!
My first QA week in review
Today in the World of Transcription & Beyond....
A Few Notes on My Day!
Initiation into the QHC
lots of great stuff in August 2009 archives!
