Charting Bloopers

I saw this one in a chart review the other night, "Pt. reports relief from rectal exam per MD"

[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."

YIKES!
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?



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Hugs, Nofear4me

A visiting psychiatrist from India was at rounds one morning when he wrote the following in the patient's note,
"He is clearly psychotic this morning. He states he has a frog in his throat."

MD actually wrote the following order:

Connect IV to F/C

I guess he had recycling on his mind!

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Recently when I was working in a hospital I was assigned to a pt. that I was told had IV fluids infusing into his bladder via a 3-way catheter. On futher exam of the chart the MD had ordered an antibotic infusion due to a severe bladder infection. We continued the infusing during the night, but still wonder how successful the treatment was since the foley was connected to a BSD bag. The treatment was stopped the next day.

I 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."

When 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

On an ER flow sheet, "16 Fr foley inserted to pt's L nare." ????????

Actually, that last one might be legit--I think they do that sometimes for very severe epistaxis, puts compression on the bleeder, I think.

Unfortunately, it was written on a little old lady with SOB!