Charting Bloopers - page 29

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   JosieKitty
    One busy day in the ED, a doc told me to set up for a pelvic exam in room 10.
    Imagine my suprise (and the patient's!) when I wheeled a pelvic cart into the room and HE apparently knew what it was because HE said "Oh, I don't think so!" I had to inform the doc that the male patient refused the procedure...
  2. by   bjlyst
    i read recently in the nurses notes; pt. alert and oriented, "may he rest in peace."
  3. by   UM Review RN
    Found these H&Ps recently:

    Patient has quite a large stomach. In fact, he actually looks quite a bit like a Buddha.
    Patient then went into asystole and was coded. Obviously, since patient is now an inpatient, code was successful.
  4. by   SeeK
    i once wrote in a paranoid schizo's chart that had a BS on the lower side...."offered patient a snake"....of course you know i meant snack and even after i drew my line through it you could tell what it said and i was teased for awhile....lol
  5. by   SeeK
    oooohhh and my husband is an ICU nurse, he said one dr. wrote in the patients chart...."if patient codes, be sure to SLOW code him, IF he makes it through the night, get chest xray"...my husband called him and said "i dont think you should of wrote this in the chart....the doctor first couldnt understand why but he must of consulted with peers because he was on the floor 15 min later and re-wrote the order...thankfully for his sake his had been the only order on that page so he could just throw it away
  6. by   JWaldron
    Just last night at work I checked an H&P - the admitting Dx was CVA, but the history stated that the patient tripped and fell at home, hit his head, had a subdural hematoma, a subarachnoid hemorrhage, a non-displace occipital fx...and NO mention of a CVA anywhere in the history. TBI or CHI alone would have been good enough to get this guy into RHB, where I work - the doc didn't have to find some Dx that wasn't substantiated by the hx! The surgical history, Item 2. was "Awake, alert and oriented repaired in 2003." Maybe a lobotomy?? It must have worked, whatever it was, because this poor guy has no retention of anything, and can't seem to remember much of the past either.

    Savvy
  7. by   BJLynn
    I saw a physician write "Patient's PERRLA".

    I sat down next to him and said, "Wow, that is amazing, I got to go look at that patient again."

    He said (rather annoyed), "Why?"

    Me: "Because that left eye has got to be the best damn prostetic I have ever seen!"
  8. by   evans_c1
    we had a nurse on our unit chart "pedal pulses palpable bilaterally" on a bilateral amputee.
    the doc amusingly inquired if it was the dorsalis pedis or posterior tibialis.
  9. by   jennyfyre
    Here's one I almost put into a computer order. Our gyn on-call admitted a patient and wanted to be present for the pelvic U/S... he said he wanted to watch in case he saw something the tech didn't. When I was entering the order, I wrote "please page Dr. when patient goes to U/S, he wants to watch" THANK GOD I always double check myself before hitting the enter order!
  10. by   grace90
    The other night on the surgical floor, I had one patient that was s/p self-inflicted abd. GSW and another one that was in a for a bowel obstruction which was resolving without surgical intervention (and 8 other patients , but that's beside the point ).
    Anyway, when I opened the computer charting on the bowel obstruction I saw that the last nurse had charted about an incision and JP drains on him. I almost jumped up and took another look at his belly, but instead I double-checked the 'procedure' section of his chart and saw that I was correct, he definitely had NOT had any surgery. She must have confused the GSW with the bowel obstruction when she charted.
  11. by   MALE*RN*777
    Had a doctor ask me about a monthly note that stated "Pt. continues to be on coking precautions" and wondered if they perferred Pepsi. (choking)
  12. by   crackerjack
    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.

    In surgery, the ENTs use a foley immediately after doing the adenoidectomy to apply pressure and stop bleeding. Once it is in place, they proceed to the tonsillectomy and remove it later. Works like a charm! Given my son's propensity towards horrendous nosebleeds, I'm tempted to take one home and keep handy for when he gets one ROFL!!!
  13. by   ChristaRN
    Just the other day I was reviewing the H&P for a 23 year old patient of mine. Under Family History, it was written "Mother died at 46 of a head and neck cancer". The next sentence was "Pt lives at home with 60 year old mother who is alive and well". So, I wonder how long that AMAZING lady was dead before she came back?!

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Charting Bloopers