My personal steam drill is the voice recognition system I use to dictate my reports. What it achieves in efficiency it lacks in even rudimentary human common sense. The dictation software is not the only thing lacking common sense. The humans who compiled its expensive "medical" dictionary option put in zillions of highly inappropriate words. It is unlikely that I will ever use "Microsoft", "Mickey Mouse" or "Godzilla" in an X-ray report, yet they visit my dictations all too often. I really miss John Henry.
I have a good friend who is a medical transcriptionist. Annually she and her plural of transcriptionists assemble months of medical malaprops into a canonical collection that they share with the rest of the hospital. She was kind enough to pass these on to me.
The patient's first name is Margaret, with an M, like in Margaret.
Complains of intermittent leftness of his numb hand.
Complains of some difficulty breathing for the last couple of hours with some shortness of breath which she says is only present when she breathes.
Recommendations: I have told the patient if she has another seizure and becomes unconscious, she is to call 911 immediately
The lower extremity was then carefully moved with the patient to the bed maintaining abduction and neutral rotation.
He normally will blink his eyes to say "yes" and will frown to say "no", but that is the extent of his verbal abilities.
Delightful elderly gentleman (56 y/o)
Conscious sedation was delivered by a registered nurse during conscious sedation.
Neosporin to his buttocks, 1 PO bid
The patient has evidence of a limping date. (gait)
Patient had circumcision in 1998 secondary to recurrent otitis. (balanitis)
She will have a blood taste today. (test)
The patient’s urine put-put was adequate. (out-put)