Charting Bloopers - page 21
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
Oct 29, '05I saw a neuro surgeon's notes once that said, among other things, that the pt's LOC had decreased and he needed to go to the OR for a ventric.
I can't remember exactly how he wrote it, but it came across that the pt needed to go to the OR because the neurosurgeon's LOC was decreased.
Nov 2, '05This happened about 2 or 3 am. Not A charting blooper but a verbal slip up.
We had a patient in with a drug overdose, her pressures were falling. Phoned the doctor who told us to give her some tylenol and make an appointment in 1 month. The nurse that called the doctor was really new and just hung up. She called him back a few moments later after consulting others and got an appropriate order. when this was told to the doctor the next am he also got a good laugh.
Dec 11, '05Quote from skapI read in a chart "Pt complaining of headache. Tylenol given as ordered. Checked back with pt one hour later and head gone!"
Didn't know Tylenol could take off your head! Yikes!
Speaking of the healing wonders of Tylenol...I work nights in the ER, and it can get hairy, even at 0300 in the am. We also use paper charting for everything, even D/C instructions. Imagine my surprise one early am when reading my own handwriting to the parents of a febrile child "alternate tylenol and motrin every 3 years". Whoa! talk about extended release. Luckily, they had a sense of humor when i explained my error.
Dec 11, '05Quote from AHarri66LOL! Oops!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."
Dec 11, '05What a hoot these bloopers would be in court....Can you imagine being on the stand trying to explain that one...how embaressing. :imbar
Dec 11, '05Quote from janine3&5Interesting...On an ER flow sheet, "16 Fr foley inserted to pt's L nare." ????????Last edit by katfishLPN on Dec 11, '05
Dec 14, '05Quote from zambeziOriginally Posted by panda_181
One 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.
you know, we had to recarpet the floors on our unit just for this reason....
Dec 14, '05My mother works as an activities assistant in LTC, but she does have to do charting. Apparently a co-worker of hers managed to chart several people as "awake, alert, and ambulatory" - two were dead, one hadn't spoken or gotten out of bed / wheelchair in three months, and the other slept constantly.
Dec 15, '05Originally Posted by janine3&5
On an ER flow sheet, "16 Fr foley inserted to pt's L nare." ????????
Actually, this I find believable. When I was doing my intership in ambulatory surgury, I saw a number of ent surguries, we sometimes used straight caths and in one case did use a foley line through the nare.
Dec 16, '05I've seen this too - the inflated balloon does a great job of controlling epistaxis. I saw it more when I worked ER than I do now, but I had a pt in RHB a few months ago w/ a gusher, and I wanted to do that in the worst way...it took the doc 2 days before he did it, and it fixed the guy quite well This particular doc doesn't take suggestions at all well. Maybe I should have just taken a Foley in and left it at bedside and said nothing.
Dec 17, '05We had a 3-4 day old brought into triage with jaundice. The pediatrician had the parents bring the child to be evaluated for elevated bilirubin. The EMT triaging wrote for chief complaint: "High Billy Rubin"
Guess what his nick name was for a long, long time?