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... Read More

  1. by   outbackannie
    MD actually wrote the following order:

    Connect IV to F/C

    I guess he had recycling on his mind!

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  2. by   khull
    Originally posted by outbackannie:
    MD actually wrote the following order:

    Connect IV to F/C

    I guess he had recycling on his mind!

    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.
  3. by   TracyRN
    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."
  4. by   Nittlebug
    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
  5. by   janine3&5
    On an ER flow sheet, "16 Fr foley inserted to pt's L nare." ????????
  6. by   prmenrs
    Actually, that last one might be legit--I think they do that sometimes for very severe epistaxis, puts compression on the bleeder, I think.
  7. by   janine3&5
    Unfortunately, it was written on a little old lady with SOB!
  8. by   prmenrs
    oops! Never mind, then.
  9. by   ratchit
    Could explain the SOB. Maybe they should have just straight cathed that nare?
  10. by   traumaboy
    Originally posted by janine3&5:
    On an ER flow sheet, "16 Fr foley inserted to pt's L nare." ????????
    foley's are great for stopping nosebleeds, the balloon works miracles
  11. by   DIPLOMATICRN4HIRE
    Originally posted by ratchit:
    Could explain the SOB. Maybe they should have just straight cathed that nare?
    ROFLMAO!!!!!!!!!

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  12. by   Sable's mom
    How about "sleeping quietly in open crib. Diapers clean and dry" on a 22 yo new MOM! Whoops.
  13. by   collinsfriend
    In regard to the pt. that had expired hours ago.. Where was the rest of the staff all day? I have seen badly spelled or poor grammatical work written by docs, RNs, LVNs,PTs, PTAs, and this list marches on. (I'm not a CNA by the way) All observations need to recorded for continuity of care. Don't blame the aide if you don't check your patient all day, AND WHO HIRED THAT ONE AND TRAINED HIM/HER ANYWAY??
    Originally posted by jkh:
    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."

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