The patient is a what? Proof those dictated encounter notes carefully

by Laura Evans, CPC on Aug 1, 2017
When his electronic health record (EHR) system's dictation software noted a history of present illness of “a warty 3-year-old man,” ER physician and former AMA president Steven J. Stack, M.D. managed to keep his sense of humor and tweeted about it (h/t Politico eHealth).
EHRs may be featuring more sophisticated voice recognition technology in their dictation software, but the issue of dictation bloopers - and just plain gibberish - clearly hasn’t disappeared. Here are some of our favorites, from the Doctor’s Lounge site:
  • The lab test indicated abnormal lover function.
  • The baby was delivered, the cord clamped and cut, and handed to the pediatrician, who breathed and cried immediately.
  • She is numb from her toes down.
  • The patient was to have a bowel resection. However, he took a job as stockbroker instead.
  • She can't get pregnant with her husband, so I will work her up.
  • On the second day the knee was better and on the third day it had completely disappeared.
  • The patient will need disposition, and therefore we will get Dr. Blank to dispose of him.
  • Patient was becoming more demented with urinary frequency.
  • The patient refused an autopsy.
Do you have a favorite dictation blooper? Share them in the comments!
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