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
Mar 4, '04 by StitchieQuote from cmggriffMaybe when the exam was over? I would be!I saw this one in a chart review the other night, "Pt. reports relief from rectal exam per MD"
Mar 5, '04 by nurseygrrlWhen 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
Mar 5, '04 by Marie_LPN, RNSaw "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....
Mar 5, '04 by FranEMTnurse, LPN, EMT-I ProA 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!
Mar 5, '04 by kathy26:hatparty: iam cna work inteaching hospital . learning how to chart wrote pts penis in tactLast edit by kathy26 on Mar 5, '04 : Reason: need help sleep deprived and scool is getting to me!
Mar 5, '04 by zambeziQuote from panda_181One of my co-workers said she saw a chart that said "Pt had large bowel movement ambulating around floor!"
I have seen this happen--more than once. It is not pretty.
Mar 6, '04 by FranEMTnurse, LPN, EMT-I ProQuote from zambeziThe 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 RNI have seen this happen--more than once. It is not pretty.
Mar 6, '04 by NurseRatchet26Quote from Lynn Casey RNSounds like a bad adult film!A collegue wrote..."pt states "slept well until nurse came in to get on patient"(instead of check on pt!)LOL!
Mar 11, '04 by Purple PrincessYes 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 frustratedRNmy fav is
"pt pleasantly confused"
and the time one of our male nurses charted that he examined mr smiths vagina
Mar 11, '04 by AIS52Two good ones-
On the floor census, "S/P CABBAGE"
on the preop checklist in the belongings section "family took toilet trees home"
Mar 11, '04 by FranEMTnurse, LPN, EMT-I Proand the time one of our male nurses charted that he examined mr smiths vagina :chuckle
Mar 11, '04 by NS_RNQuote from BJRN76well how do you spell pu$$y anyway???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)