Charting Bloopers - page 14

Found in the History and Physical section of a patient's chart who had experienced visual hallucinations while ill: "Patient vehemently denies any auditory, tactile, or old factory... Read More

  1. Visit  Stitchie profile page
    1
    Quote from cmggriff
    I saw this one in a chart review the other night, "Pt. reports relief from rectal exam per MD"
    Maybe when the exam was over? I would be!
    carolmaccas66 likes this.
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  3. Visit  nurseygrrl profile page
    3
    When I come back from work after a few days off, I read the charts of a few pts. who have been on report to see what's going on. On Saturday I saw the nurse had written on report that Ms. 'A' had an incident...ok. I went into the chart to see what had happened and lo and behold, the note read something like this...

    "Resident had incident at 10am. No c/o pain or discomfort. Oncoming shift made aware. Incident report #439 filled out."

    OMG!! First of all...she had an incident?! Well what in the HECK happened to her? Secondly...incident reports are IN HOUSE tools! you're never to write that you filled one out in a note...sheesh! :chuckle
  4. Visit  Marie_LPN, RN profile page
    3
    Saw "pt. could not recall losing consciousness" again in nurses' notes.

    Valsalva maneuver charted as "Salsa maneuver". Now i wonder, was it picante or extra chunky? Or are we talking about a dance here....
  5. Visit  FranEMTnurse profile page
    1
    A new intern to our CCU once charted attempts to cardiovert a patient in the following manner:
    Attempted to convert the patient with 200 jews, unsuccessful. Second attempt to convert the patient with 300 jews unsuccessful. Patient finally converted on the third attempt with 300 jews.
    The mental picture of three hundred rabbis surrounding a patient's bed yelling, "Convert, convert!" was too much. We nicknamed him "Call a Code or Call a Rabbi" from that day forward.

    :roll :roll :hatparty: Hee,hee,hee,hee,ha,ha,ha,ha! This one is soooo good! Hee,hee,hee!
    carolmaccas66 likes this.
  6. Visit  caffine addict profile page
    2
    OHhhhhhh Frances,

    What are we to do with you ?
  7. Visit  kathy26 profile page
    1
    :hatparty: iam cna work inteaching hospital . learning how to chart wrote pts penis in tact
    Last edit by kathy26 on Mar 5, '04 : Reason: need help sleep deprived and scool is getting to me!
    carolmaccas66 likes this.
  8. Visit  zambezi profile page
    2
    Quote from panda_181
    One of my co-workers said she saw a chart that said "Pt had large bowel movement ambulating around floor!"

    Amanda

    I have seen this happen--more than once. It is not pretty.
  9. Visit  FranEMTnurse profile page
    0
    Quote from zambezi
    I have seen this happen--more than once. It is not pretty.
    The word describing the size of the bowel movement is too ambiguous.. It should be described by a comparison to an object. ex: While ambulating, pt had a bowel movement the size of a hockey puck, Jane Doe RN
  10. Visit  NurseRatchet26 profile page
    1
    Quote from Lynn Casey RN
    A collegue wrote..."pt states "slept well until nurse came in to get on patient"(instead of check on pt!)LOL!
    Sounds like a bad adult film!
    carolmaccas66 likes this.
  11. Visit  Purple Princess profile page
    1
    Yes I've read that on charts too when I was a student nurse not very long ago at all. The woman had Alzheimer's, the man had organic brain syndrome, both hard of hearing and the third patient was stable yet couldn't talk and was obviously disoriented and only opened his eyes to verbal stimulation. Yet all three were pleasantly confused. What does that mean anyway? Crazy!!!

    Quote from frustratedRN
    my fav is
    "pt pleasantly confused"


    and the time one of our male nurses charted that he examined mr smiths vagina
    carolmaccas66 likes this.
  12. Visit  AIS52 profile page
    4
    Two good ones-
    On the floor census, "S/P CABBAGE"
    or
    on the preop checklist in the belongings section "family took toilet trees home"
  13. Visit  FranEMTnurse profile page
    1
    and the time one of our male nurses charted that he examined mr smiths vagina :chuckle
    carolmaccas66 likes this.
  14. Visit  NS_RN profile page
    1
    Quote from BJRN76
    We all got a good laugh at work after reading a consultation from our ID doctor. She wrote...pt has large amount of ***** drainage... we decided that purulent might look better. (Keep in mind it was a slow day)
    well how do you spell pu$$y anyway???
    LOL
    carolmaccas66 likes this.


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