Chart check quote of the week

I found this typo while doing chart checks yesterday:
"Abused by history"

Thanks anyways

Honesty may not always be the best policy. For instance, look at this quote I found in a patient's assessment:

"Military: He has never served. He says he applied in high school, but they turned him down for psychological reasons. When they asked why he wanted to join the army, he said it was so he could kill people."

Time for a new dictation service

I found this in a patient's chart this week:

"I will call the client's PCP about her gigolo's vain dissension."

It's called JUGULAR VEIN DISTENTION!

The sad tale of Not Quite Bright

IntimidatingShrink has been a forensic psychologist for a long time. In addition to doing standard mental health assessments on inmates, he also gets to do competency and "how likely are you to re-offend" exams. He keeps us posted whenever "our people" wind up in the criminal justice system.

I got a call from him the other day.
"You have a Not Quite Bright on your caseload, right?"
"Yeah..." I've got about ninety people on my caseload. It takes a minute to remember who's who without accessing our computer records.
"You may want to put his case on hold for a few months. He's back in jail in meth possession charges."
This surprised me. "He just was in last month on meth charges. Did he jump bail?"
"Mr. Bright got arrested yesterday when he went to his court date for last month's meth charges. He actually had more meth in his pockets that he brought to court!"

Chart check quote of the week

"I believe the client is somewhat manic. Although his given name is Rodney, he introduced himself to me as "Hot Rod" and insisted that I call him that throughout the assessment."

Chart check quote of the week

"The client is a 48 year old white male, married once, divorced once, currently living under a tree."

Chart check quote of the week

For a developmentally disabled client: "Her appetite is increased. The staff say she will eat handfuls of ketchup when they're not looking."

I know people do strange things, but eeww!

Chart check quote of the week

Dr. Analytic has a way with words:

"I called ExpensiveDrug pharmacy to order the medication, but they haven't prescribed for the client since 2004. I then called OverpricedMeds, but the client does not get medications there either. It appears I have failed at playing "guess the phamacy." "

Chart check quote of the week

"I can only imagine how I would feel if my drums were my most prized possession and my brother stole them for drug money."

Drug of choice?!

As I was doing routine chart checks last month, I came across this notation in the initial assessment of a new client:

"Substance abuse: Client says he smokes marijuana and snorts Smarties."

I wasn't sure if this was a new name for a street drug, so I asked the therapist who'd done the assessment to clarify.

"No, he snorts crushed Smarties candy. He even did a line in my office."

Time to chart veeery carefully...

Because it's not like I wasn't paranoid about my personal safety before I started this job....

Tee shirts with bizarre slogans are very popular among our clients. I've seen people wearing shirts that said everything from "Can't sleep... clowns will eat me!" to "If sex is a pain in the @$$, you're doing it wrong." The thoughts expressed may not be "appropriate," but they're usually good for a few laughs and conversation starters.

But tell me what I'm supposed to say to a wild-eyed, disheveled gentleman who reeks of stale sweat, vomit and booze wearing a shirt that says "I like you--I'll kill you last!"

Words you don't want to see in a chart, part 2

I was doing a routine chart review last week, and I ran across this entry in one of the doctor's notes:

"Abuse history:
She says she experienced domestic violence from her first husband, but then she went out and bought herself a nice baseball bat and after that he was very good to her until the day he died."

I'm glad it worked for her, but wow.

You deserve to be treated with love, respect, and dignity. If you are experiencing domestic violence and feel you're in immediate danger, please call 911. If you just need to talk to someone, call 1-800-799-SAFE or visit the National Domestic Violence Hotline for more information.

Words you don't want to read in a chart

Usually medical charting follows a time-honored format: Situation (why they're there to see you) Background information, Assessment information, Recommendations (changes in medications, etc.) It's generally pretty dry stuff, but occasionally things jump at out me as I'm reading through the patient's previous visit notes.

(On a developmentally disabled client who lived in a group home:) "He was fired from work after he destroyed the mail box and ran naked through the streets."

(From a patient complaining of right-sided numbness that started three days earlier:) "I am worried that he has had a small stroke, and I told him he needs to see his PCP ASAP. Although, given his history of heroin abuse, I am also concerned that his condition may be due to peripheral nerve damage after laying on the floor for an extended period of time--essentially comatose."

(Concerning a woman who had a history of asking for early refills on her Xanax, claiming her purse was stolen, pills were lost, etc.:) "Ms. Histrionic seems to be making a full-time career out of requesting early fills on her meds and I told her in no uncertain terms that she needs to do a better job of keeping track of her belongings."

(On a gentleman who'd recently gotten out of jail and was required to seek mental health treatment as a condition of his parole:) "Legal history: Client was arrested at age 8 for possession of methamphetamine. He says he used to smoke it with his mother..."