Charting Bloopers - page 2
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! Angela... Read More
- 6Jan 14, '01 by nofear4me23[QUOTE]Originally posted by AHarri66:
[B]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."
At our hospital they allow aides to write in nurses notes!! This is a true note, "patient don't move all day. Just lays there." When second shift arrived a code was called on the mentioned patient. The doctor stopped the code and yelled, "this pt expired hours ago" As nurses on our unit we are trying to stop the aides from note writing. Does anyone know the law from Pennsylania?
- 1Jan 26, '01 by khullOriginally posted by outbackannie:
MD actually wrote the following order:
Connect IV to F/C
I guess he had recycling on his mind!
- 4Jan 31, '01 by TracyRNI must confess that I, too, described thick, white drainage as "***** ." Luckily, it was while I was in nursing school when we all spent time agonizing over our notes and first wrote them on scrap paper. I did figure it out before it went on the record but we had a great time laughing about it at post conference and it still makes me chuckle whenever I write "prurulent."
- 5Jan 31, '01 by NittlebugWhen I was a new grad I had a patient with a staph infection in her right eye and cellulitis of the surrounding tissue. It was nasty !! Lots of pus and drainage.
I charted (sometime between 3-5am) right eye- red, swollen P,U,S,S,Y.
The next night I caught it. Funny though, the girl in the next room who had just had a baby 2 days prior, (I don't remember her diagnosis) called me in the room and asked if I would look "down there" to see why she started hurting so bad. When I looked, she must have had some kind of abcess because the labia majora on one side was red and swollen