Charting Bloopers - page 3
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! Angela... Read More
- 3Feb 19, '01 by collinsfriendIn 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."
- 5Feb 21, '01 by daisieI work in a nursing home. The other night one of my aids called me over the call and said, "Mr. ____ has a bad rash on his prenatal area and needs some cream." I was laughing so hard and she came out of the room and said, "Are you laughing at me?" I could only shake my head 'yes.' I finally explained to her what prenatal was and told her she meant perineum.
- 17Feb 23, '01 by laurascThis happened years ago when I worked on a general surgery floor. A med student had to do an admission physical on a rather voloptuous young woman. On the assessment sheet under "breasts" he wrote "Big and beautiful."
Needless to say this med student got his posterior cooked by the staff doc.
- 51Mar 15, '01 by TerreA new intern to our CCU once charted attempts to cardiovert a patient in the following manner:
Attempted to convert the patient with 200 jews, unsuccessful. Second attempt to convert the patient with 300 jews unsuccessful. Patient finally converted on the third attempt with 300 jews.
The mental picture of three hundred rabbis surrounding a patient's bed yelling, "Convert, convert!" was too much. We nicknamed him "Call a Code or Call a Rabbi" from that day forward.