I actually read this in a chart

[HyperRNRachel]

I had several different "what the H***" moments while reading charts this past week. The first obvious mistake was a "client who is exhibiting increasingly bizarre behavior since the patient's died", missing some information I would say, or did the patient die?? Looked alive when I saw him. The second one, the same guy, the client is a 76 y/o black male, chart stated...."76 y/o white male"??? Did the guy change color?? Maybe since he is dead, his color also changed! Same chart, now looking at the x-ray report, which states, "gun shot pellets seen is the posterior cranium" then in the conclusion it states, "no obvious signs of trauma" HMMM I'm not a doctor but I think bullet fragments = signs of trauma!

The second chart of a seriously depressed female client with cervical cancer. The doctor wrote " mood and affect, normal" Considering she would not speak to anyone, was screaming in pain, had no visitors other than her mom, and had wasted away to skin and bones I think mood and affect = not normal. I kept wondering if the doctor was actually trying to keep her out of hospice, because his job (in his own words)

"Is to treat patients and not give up!" Good thing the social worker was there....she had different views on this. Wow can you say EGO???

[KibbsRNstudent]

WOW! did you bring these mistakes to a supers' attention? That is just wrong!

[kids]

Just curious...

Were these hand written notes or dictated and typed notes?

If they were typed the errors are just as likely to be the transcriptionist's.

Not to be difficult but...

We all think one thing and write another from time to time, Docs are no different.

"Normal" is all relative. If the ill woman's behavior has been as you discribe for a period of time in may be "normal" for her (tho 'unchanged' would have been a better word to use).

The "shot gun pellets to the cranium/no signs of trauma" makes sense to me. The x-ray would not show the soft tissue wounds to the scalp created by the pellets. I would read that as the pellets did not penetrate to the brain or cause damage to the skull.

[HyperRNRachel]

I actually leave notes in the charts, where it can be seen, if I have questions. If it's a translation problem the doctor can handle it without further embarassment. In the second case, I acted like I did not understand the doctors reasoning for putting "mood and affect, normal" the nurse and social worker both started to question why this woman was not being considered for hospice, when it was very obvious she needed more than what was being medically provided. I had to leave the floor on time (got in a little trouble the day before for not leaving on time) , but I still had time to open a can of worms, and the social worker looked ready to battle. I will not know until Wed. what the end result was.