Often, doctors are too busy to type their own progress/history & physical/ED admit/surgical notes. So they dictate them. They dial up a phone number and dictate over the phone to a recording that then is analyzed by either a computer or a person (I’m not sure actually…maybe I should ask next time I hear one). Sometimes its annoying because they do it on the phone in the report room where I’m trying to have lunch and watch an episode of 30 rock on my iPod. However, it’s funny to listen to a doctor dictate because they have to also dictate their punctuation. It sounds a little something like this… “patient presented to the emergency department complaining of extreme cramping abdominal pain period he stated it began the night before after consuming a large McDonalds meal comma after which he developed the pain and eventually vomited several times which provided partial relief of the pain period this relief was only temporary comma and he developed increasing abdominal pain overnight comma and also some explosive loose stools period”
I say that I am unsure whether it is a human or a computer who analyzes the dictation because some of the transcription/translation errors are so funny they almost have to be from a computer. Or a guy with a degree in IT or something like that who can type fast and navigate his way through dictation software, but has no idea what a duodenum or a vulva is.
Example A: a patient was admitted for a gangrenous lower extremity that needed to be amputated mid shin. This is called a “below the knee” amputation for obvious reasons. (as opposed to an “above the knee” amputation) When we healthcare professionals talk shop to each other it is often shortened to “below knee” amputation, or BKA. So here is an excerpt of this patient’s discharge summary. (paraphrasing, obviously) “Patient with gas gangrene of the left lower 3rd through 5th toes. Did not respond to IV antibiotics and developed symptoms of sepsis which required a transfer to the CCU and an eventual bologna amputation.” …. it took me a while to even get it . I was confused at first. What the hell? Bologna? Then I read the sentence out loud.
Sometimes a fresh doctor or medical student does the dictating and forgets to use medically correct terminology, instead opting for a more lay term their dad used when they were a kid and scraped their chin on the driveway after riding their brother’s skateboard on their hands and knees (that never happened to me…) . The medical term for pus is “purulence” and the adjective is “purulent”.
Example B: patient admitted for a postoperative wound infection that they waited a good two weeks for it to stew and brew a nice rotten stinky hole in their abdomen before they went to the doctor. The ED resident’s admit note sounded a little something like this, “Patient presented with leukocytosis and fever, blood cultures drawn and empiric Vanco started. Upon inspection it was noted that patient had a very large, deep, foul smelling pussy area.”
Somebody should really do some proofreading. Example B must have been transcribed by the IT graduate, and example A must have been the computer. Lord knows I hope they never cut off my bologna or get a whiff of my crotch and live to tell the tale.