Charting Bloopers

Sable's mom · Feb 17, 2001

How about "sleeping quietly in open crib. Diapers clean and dry" on a 22 yo new MOM! Whoops.

collinsfriend · Feb 20, 2001

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??

Quote

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."

daisie · Feb 21, 2001

I 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.

laurasc · Feb 23, 2001

This 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.

Nole99RN · Mar 12, 2001

In response to the KAY CIEL post...That is an actual name brand of KCl which is obviously known as potassium. Just thought you should know.

Terre · Mar 15, 2001

A 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.

tangrene · Mar 16, 2001

OR he wanted to irrigate the patient! IV BAG of 1000cc or 3000cc of ns, depends on how much you want to irrigate. IV is just a standard term in charting in this case. Or maybe the patient didn't have a Foley... LOL.

Connect IV to F/C

I guess he had recycling on his mind!

Current motto: It's even worse than it appears.

tangrene · Mar 16, 2001

UHHH could the patient have had a nose bleed or some sort of facial injuries?? Foleys work great to put pressure in areas you can't pack with guaze easily. Remember the Caldwell Lucs?

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Originally posted by janine3&5:
On an ER flow sheet, "16 Fr foley inserted to pt's L nare." ????????

Lynn Casey RN · Mar 18, 2001

A collegue wrote..."pt states "slept well until nurse came in to get on patient"(instead of check on pt!)LOL!

lpnandloveit1 · Apr 6, 2001

from a nursing note. 7 formed fecalettes floating in the toilet. I often wondered if they all got in line and did high kicks

TriciaRN · Apr 18, 2001

Quote

Originally posted by ClariceS:
I recently saw a "add 20 mEq Kay Ciel to existing IVF" order also. Maybe these docs were trained at the same place.

We also had an order recently that to us really brought into question the integrity of the writer. The order was for "1 baked potato p.o. bid". First, where else would a baked potato go and secondly, dietary requests do not need to be written by a doc in the orders sheet!

LOLOL, I had to write in on this one. Like potatoes would go other places? hehe.

Oddly enough, I did see a dietary order like the potato one- on my patients charts once as well. It was something like 6 oz Rice po BID. It looked kinda funny, but I think it was for some GI purpose, LOL... Thanks for the laugh.

TriciaRN · Apr 18, 2001

Quote

Originally posted by RNkat:
From the physician progress notes on a patient with a glass eye:

"PERRLA"

Hmm, guess that doc needs a new assessment class, ROFL!?