When dictating reports, doctors are attempting to memorialize certain facts and thoughts in print. If their thought processes involve a rambling, stream-of-consciousness approach to the English language, theyare likely to dictate medical gobbledygook.
Each one of these statements was dictated by a licensed physician. Diagnose what is wrong with the dictating doctor's statement and write your own version of what the physician failed to communicate.
"This 72-year-old male was discharged from the hospital about a week ago. Since home, he had been doing fairly well as regards his breathing, but for the past few days the wife states she has had trouble moving his bowels and the patient has really not had a good bowel movement since he left the hospital."Diagnosis:________________________
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Corrected Text:
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"She states that while driving her car she was broadsided on the right front by another car that ran a red light wearing a seatbelt and shoulder harness apparatus at the time."Diagnosis:
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Corrected Text:
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"This five-year-old....uh, sentences, can't, uh...words can't put together...uh, says words but don't make sentences, uh...the sentences are incomplete but can't make words..."Diagnosis:
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Corrected Text:
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"The patient was initially started on ampicillin and ceftazidime for fear of Pseudomonas from toilet bowl water, which he received for a total of seven days."Diagnosis:
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Corrected Text:
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"The lesion was removed from the right tragus region and from the left helical rim, changing gloves and instruments between the two sides and sending them to the pathologist."Diagnosis:
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Corrected Text:
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"At this time, using a #0 Vicryl, the entire cuff was run. The anterior cuff was closed, and the posterior cuff was closed to themselves. The anterior and posterior cuff were not closed together; only the anterior cuff was run by itself, the posterior cuff was run by itself, and the cuff itself was left open."Diagnosis:
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Corrected Text:
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"By the way, this man's chart was labeled William, his original report was labeled William, his name is Norman, not William. Forget the name change on William/Norman, because Norman's name is really William but he goes by Norman but legally it is William."
Diagnosis:____________________________________
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Corrected Text:
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"Discharged ambulatory with new husband."Diagnosis:
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Corrected Text:
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