Charting blooper

[NRSKarenRN, BSN, RN]

received this note tonight from our utilization review/coder rn:

this is your laugh for the night - one of the intake staff wrote:

pt has bowel cell ca of the face (basal cell).

i took such a fit of laughter.

thanks

glad the staff didn't copy that one.

[tnbutterfly - Mary, BSN]

[VivaLasViejas, ASN, RN]

Uh.......OOPS!!! :rotfl:

Gotta love it when the transcriber doesn't have all their med. terminology down yet....I read an H & P note once on a new ALF admission who'd been hospitalized for CHF which said: "We will diurese her aggressively, then watch her eyes and nose for a couple of days and check lights daily w/ probable discharge to ALF/ICF....etc.". Of course, the non-medical staff couldn't figure out why anyone needed their "eyes and nose" or their "lights" monitored, but the administrator (a former EMT) and I were howling!

[GitanoRN, BSN, MSN, RN]

i love this kind of errors!!!

[fsaav]

Some things I've read in ER notes:

The patient was recently diagnosed with "ear and double bowel syndrome." (Irritable bowel syndrome)

The wound was urinated with normal saline.

These always crack me up. Made me feel a little better when I found out the ER physicians use voice recognition software for their notes.

[Rose_Queen, BSN, MSN, RN]

Some.... interesting procedures as entered by surgical scheduling:

-peritoneal craniotomy (is that a new approach requiring extra long instruments, or does the patient suffer from cranio-rectal inversion?)

-Cabbage or cabage instead of CABG (which comes up automatically in the system, and they have to delete and retype. Not to mention food isn't allowed in the OR.)

-exploratory laparotomy for bowl resection (how'd that get in there?)

[CapeCodMermaid, RN]

One of my nurses was an excellent nurse, but a rotten speller. I was doing chart reviews and found on the dementia unit she had charted "cognitive deficate". Once I stopped laughing I asked her if it meant "s**t for brains"!!?!?!