Charting Bloopers

Ronna · Jul 22, 2004

Pt came up from ER with admitting dx of "Sinkable episode"

Maybe they thought that he had drowned. able to sink

imnmk_rn · Aug 1, 2004

We got a kick out of a sliding scale insulin order:

Blood glucose 0-70 1 amp D50 IV

Blood glucose 70-150 Do nothing....

The RN taking care of the pt claimed she could take the rest of the day off, her pt's blood sugar was 110! :)

urbancowgirl · Aug 1, 2004

""I recently saw a "add 20 mEq Kay Ciel to existing IVF" order also. Maybe these docs were trained at the same place."

Almost have to feel some compassion for these poor docs. Anymore they have to spell everything out! They got away with IVF? :chuckle

urbancowgirl · Aug 1, 2004

Once, I saw a resident had written 'p.b.b.b.s' in his progress note (pine-box-by-bedside!!!) I assumed he meant he didn't expect the guy to live much longer.

vablueyes · Aug 3, 2004

This is from a chart of an elderly lady from one of our "Higher Learning Centers" who had had a mastectomy, has alzheimers, and is a bit combative:

.....left breast still missing (they grow back??), I was beat off before I could get a good listen (that may be too much information)...

This same doc has also written diagnosis as "Pork Chop enteritis." and has asked patients if they want a pine box or treatment..

Mistynurse · Aug 3, 2004

I saw this one on a long-term care note: Patient is pleasantly psychotic. :chuckle

txspadequeenRN, BSN, RN · Aug 3, 2004

I do medicare charting and we frequently write "staff to assist pt with meals, ADL's" and etc.. Anyway I had just finished a 6 week course of Micro HELLLLL ,I went to work one weekend looking over my charting and instead of writing staff I had wrote STAPH on every chart....... :rotfl: :rotfl: . MY whole unit laughed for weeks however the big boss didnt think it was that funny!!!!:rotfl:

jannecdote · Sep 5, 2004

Here are some of my favorites:

1. A patient had died and was found in this unfortunate condition by her physician during early morning rounds. The primary nurse charted: "Dr. X walked into room and patient's heart stopped." :chuckle

2. Actual entry of a staff nurse that we were assigned to during clinicals: "Pt. expelled a large green turd."

3. We coded an elderly man briefly one night a little after 2 o'clock in the morning. The ER doc said the patient was too stiff--rigor had already set in--obviously a lost cause. Unfortunately, the nurse taking care of him had already finished his charting out and had a 6 o'clock entry that matched all the other entries timed from midnight on: "Pt. asleep, resp. eupneic, no s/s distress."

dazzle256 · Sep 5, 2004

My own mistakes.......

As a nursing student and doing clinicals in a nursing home I charted a patient was molting ......my instructor asked me if my patient was a bird.

Then one day while working in the ICU it was a particularly hectic day one of my patients died. I charted the death and circumstances on the wrong patient. Fortunately another nurse caught it although it was two days later when she was reading the nurses notes on her patient.

FranEMTnurse, CNA, LPN, EMT-I · Sep 5, 2004

txspadequeen921 said:

I went to work one weekend looking over my charting and instead of writing staff I had wrote STAPH on every chart....... MY whole unit laughed for weeks however the big boss didn't think it was that funny!!

Well it certainly made me laugh out loud!!

kberl · Sep 21, 2004

AHarri66 said:

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 hallucinations."

YIKES!

An actual order in a patient's chart who was a very non-compliant diabetic refusing to eat his prescribed diet:

Change diet to 10,000 calorie ADA diet

Back the food truck up to the patient's mouth and dump it in

Even funnier, it was an endocrinologist that wrote it! I guess we all get tested by some patients...

FranEMTnurse, CNA, LPN, EMT-I · Sep 21, 2004

kberl said:

An actual order in a patient's chart who was a very non-compliant diabetic refusing to eat his prescribed diet:
Change diet to 10,000 calorie ADA diet

Back the food truck up to the patient's mouth and dump it in

Even funnier, it was an endocrinologist that wrote it! I guess we all get tested by some patients...

Change in diet order $50.

Endochrinologist order $150.

Mental picture of back food truck up to Patient's mouth and dump it in PRICELESS!!