Best MD note - page 3

There may or may not be a thread like this but I couldn't resist sharing. This weekend I was digging through my patient's chart trying to learn more about his history when I came across a note by the... Read More

  1. by   GitanoRN
    Quote from cbs1980
    One of our pediatricians .charted child bitten by dog 10 days ago mom states dog is fine, nothing was ever charted about how the child was doing.
    Hey some people have their priorities in that order... LOL... Aloha~
  2. by   JMBnurse
    Quote from logachelle
    In surgical report on pt who had to have whole apple removed from rectum..."Instructed pt in proper intake of fiber."I kid you not. Hee Hee!

    Hahaha! Many years ago, my father, who was a CRNA, and I worked at the same hospital. One night he was called in to give anesthesia for an emergency procedure. After the surgery, I saw his notes and the procedure name was: "Removal of foreign body from rectum (shampoo bottle attached to stick with rusty nail)". I never forgot that story and years later at another hospital, I told the story to a surgeon and asked about what interesting things he had removed over the years. He rattled off a list of typical items and then said, "Dr. Johnson removed a squash".
  3. by   Syrenia
    I had a doctor with a great sense of humor. Couldn't remember to write orders to DC a saline lock before dismissal. One time after I had reminded him to write that, he then also wrote "please dress patient in street clothes before discharge."

    Another time, we had given a resident a flu shot, only to find out he had already gotten one that season. Informed the doc, who replied "let me know if he develops an 'S' on his chest or get the urge to leap tall buildings in a single bound."
    Last edit by Syrenia on Aug 17, '12 : Reason: spelling
  4. by   Keld401
    In an H&P dr charted "pt's o2 sats 120's on non-rebreather but quicky drop to the 00's without it." Haven't quite figured out how an o2 sat can be more than 100%, or 0%. Hopefully it was a transcription error!
  5. by   Kay28
    My favortie was a FEMALE patient who underwent a TRANSVAGINAL ultrasound. The results read: No testicular torsion noted.
  6. by   GitanoRN
    Quote from Kay28
    My favortie was a FEMALE patient who underwent a TRANSVAGINAL ultrasound. The results read: No testicular torsion noted.

  7. by   sereneintexas
    At one home health agency where I worked, I frequently saw in the admit paper work of female pts that they had a hx of an orchiectomy. Then I noticed that these entries were all made by the same nurse. I asked her one day if she knew what an orchiectomy was and she responded that she did not. I pointed out to her that she had entered this on a number of pts charts. She then became defensive stating that she only copied what the doctor had written on the discharge sheet.
  8. by   GitanoRN
    Unquestionably, I hope you shared your knowledge with this nurse, and for the newbies out there "orchiectomy" is a form of castration typically if testicular CA is suspected. BTW, your post still funny when one is familiar with the procedure... ALOHA~
  9. by   Sugarcoma
    An expiration note on a patient that read:

    Called to bedside by nursing to assess patient. Patient transitioned to comfort care and extubated at 1205 a.m. per family request. Asystole on monitor. Unable to palpate central or peripheral pulses. Chest examination reveals no rise or fall. Bilateral breath sounds present with lungs CTA. Unable to auscultate heart sounds. Patient pronounced deceased at 1208 a.m.

    I did not realize you could be breathing and dead.

    An ambulance run sheet on a pt. brought to ER following a GSW to the leg: Pt. inititially refusing transport. Pt. states "I want to finish my fried pork chop first." Pt. agreed to transport when allowed to bring the fried pork chop with him.
    Last edit by Sugarcoma on Oct 23, '12
  10. by   Renepoo
    Had a History and Physical come from the Main hospital on a patient that the doctor stated "I am currently suffering from a migraine headache so I am not so sure my dictation is entirely correct". Wow.....why didn't he just wait to dictate after thus said migraine was gone??? I was amazed and horrified!
  11. by   dirtyhippiegirl
    Came across a nurse communication order that read: "Please provide pants for the patient. Thank you very much!"

    Initial diagnosis of "flaming pumpkin vs. pedestrian" (which was an accurate portrayal of how the patient got burnt.)
  12. by   rehabwoundnurse
    Had one doctor who would chart things like "family tree doesn't branch far" and "****, we've tried everything and still don't know what's going on!" And same doc also charted "this patient to dumb to talk to, he understands nothing". A little harsh doc!
  13. by   skylark
    I recall a doctor who used to write OBTAA in the notes of regular attenders who never had anything wrong and just wanted to tell him their entire life story over and over.

    When asked, he told me that the 'official' meaning is "observe before taking any action".

    And the unofficial?
    "One bl***y thing after another!"