Charting Bloopers - page 27

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   rninme
    These posts are great!!

    Here's one of my favorites written by ID in the progress notes of a long-term vent patient we had in ICU:

    Day 445.
    Here longer than the hostages in Tehran, with much less hope.

    and this one, written by a very tired noc shift RRT....pt remains being ventilated.
  2. by   ayla2004
    Quote from HappyJaxRN
    WHAT??? Never heard of such a thing. :chuckle I guess where ever this is they don't have nose bleed kits...ya know the thing that looks like a tampon that is inserted into a nare....has a string hanging out....a foley cath in the nare? I have to ask around about that one...hey, whatever works! :chuckle
    I'v seen it in A&E pt had the worst nosebleed iv ever seen they thought it may be a GI bleed, ENT doc tried packing it normally this didn't work, so a fellow student stood hold a foley coming out a a patients nose.
  3. by   ails
    Our teacher always tells us that in writing nurse's notes, it should include the whereabouts and activities of the patient. Here's something my teacher told us. It's not exactly the same but it goes like this:

    [...assisted Patient X in standing up from bed, walked three steps toward the door. Then, turned the knob and opened the door. Walked 10 steps...]

    Hahaha...too specific!
    Last edit by ails on Jun 28, '06
  4. by   RainDreamer
    When charting a few weeks ago, instead of typing "blowby", I typed "blow boy" :imbar
  5. by   jaylonot
    lol
  6. by   banditrn
    Quote from ayla2004
    I'v seen it in A&E pt had the worst nosebleed iv ever seen they thought it may be a GI bleed, ENT doc tried packing it normally this didn't work, so a fellow student stood hold a foley coming out a a patients nose.
    Wonder why they didn't use a suction cath?
  7. by   fetch33
    Quote from TriciaRN
    Hmm, guess that doc needs a new assessment class, ROFL!!!!!!!!!!! :-)

    ------------------

    I remember an old, scruffy oncologist from years ago. He actually would walk up to the patient, move his stethocope over the chest.... even though the ear pieces were clasped around his neck instead of in his ears Always wondered if the patient's caught on?
  8. by   OR2ER
    saw this charting from one of the nurses..."patient sleeping peacefully"..
  9. by   JWaldron
    Quote from banditrn
    Wonder why they didn't use a suction cath?
    I think the idea is to inflate the balloon and apply pressure w/ it. That's the way I've seen it done. I don't understand what you would do w/ suction cath except to remove the blood, which wouldn't stop the bleeding. Is there something else you could do w/ it to control the epistaxis?

    Savvy
  10. by   perfectbluebuildings
    Quote from or2er
    saw this charting from one of the nurses..."patient sleeping peacefully"..
    what's wrong with this one? just curious... i have charted "pt sleeping quietly" before...
  11. by   UM Review RN
    Quote from Rayrae
    what's wrong with this one? just curious... i have charted "pt sleeping quietly" before...
    You can describe "sleeping," you just can't say it:

    "Pt resting with eyes closed, skin pink, warm, dry, and respirations even and unlabored."
  12. by   perfectbluebuildings
    huh... didn't know that... why?
  13. by   elizabells
    Quote from Rayrae
    huh... didn't know that... why?
    I imagine it's because you don't actually know that the pt is sleeping - might just be lying quietly w/ eyes closed. Not to say that it's not used all the time.



    I've seen a number of folks use their steths with the earpieces on the mastoid process.

close