Fun with charting.

Nurses General Nursing

Published

Specializes in CDI Supervisor; Formerly NICU.

I review charts. Here are a few things that caught my eye over the last few weeks. Houston, we have a charting problem...or a transcription problem. What are some of your favorites that you have seen?

agreeing discontinues artery toe would keep her on discontinuing

Add Tamiflu 75 milligram twice a day pending influence that test result

56 y/o male patient who was found on the flow.

The patient has presented with a recurrent vomiting for last 3 days and recurrent scissors.

Patient feels much better and headache has notoriously decreased.

I think it is better to do a formal chest CT noncontrast to be sure there is no a tumor producing the obstruction considering his high wrist.

in to the emergency room complaining shortness of breath on mild exertion. Also at rest everything started this morning when he was having breakfast he start experiencing problems catching his hair .

PLAN: Continue with aggressive brain killer.

The patient has been 6 cents 3 days ago

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Specializes in Med/Surg, Ortho, ASC.

New auto-transcription system:

Pain is significant at times. Rest modifies his symptoms. She squatted her bed at work felt a pop in his knee and since that time as had significant symptoms.

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XX is a 48 y.o. male resents to the office with a piece of right shoulder. Pain 5/10 on a constant basis. Patient had a history of one half months ago, showing in the yard hit a rock felt a snapping sensation.

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Specializes in CDI Supervisor; Formerly NICU.

Today:

patient complaining shortness of debt

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Specializes in psych, addictions, hospice, education.

gosh, I wish I had shortness of debt! I think...?

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Specializes in Geriatrics, Dialysis.

Too funny...shortness of debt! This is a diagnosis I wish I had.

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Specializes in OR, Nursing Professional Development.

I've seen quite a few humorous charting done by voice to text programs. Some of them are obviously issues with the voice recognition, some are probably influenced by accents, and some are obvious English as a second language issues. Some of my favorite with the voice recognition software is the last names that might be common words or similar to common words. For example, a certain chocolate company would be two words (female pronouns) instead of a single name.

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Specializes in Pediatrics/Developmental Pediatrics/Research/psych.

My sister is a transcriptionist, and she once called me to ask if it is possible for a client with double BKA to have pedal pulses. I told her that we may be surprised...

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I almost make this one error on a daily basis. In our computerized charting for care plans, I have to type what happened on my shift. Sometimes SHIFT gets typo-ed to SH*T :nailbiting:. Hopefully I have caught and corrected the errors I have made.

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Specializes in nursing education.

I saw one with what looked like it was supposed to be in regard to a CT of the pelvis, except the note said Elvis. The Dragon capitalized Elvis!

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Specializes in Med nurse in med-surg., float, HH, and PDN.

I saw one once where it was said the pt had c/o 'shuttering'; the pt had actually said 'shuddering' by which I took it to mean he had been shivering:sarcastic:.

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Under BM: Patient had a large brown stethoscope.

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Specializes in hospice.
Under BM: Patient had a large brown stethoscope.

Ow. I'm thinking one might need a little topical lidocaine after that!

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