Charting Bloopers - page 33

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   Rizpah
    Internal message from RN supervisor to charge nurses: ****'s wife is concerned about an increase in confusion (likely related to recent increase in Duragesic patch). Until he develops a tolerance to the increased patch dose, please try Regular Tylenol if the PRN needed to decrease confusion. (Unless pain is severe, then use the stronger PRN). Thank you.

    Now I know, what she's saying is to try prn tylenol instead of the prn PO narcs he has available. But another staff member asked me, "since when do we use tylenol for confusion?" :roll
  2. by   carlarn
    I was working in the ER at the time and was writing discharge instructions. The patient had been seen and treated by the plastic surgeon. I was standing at the counter writing and apparently listening to my colleagues talking because I caught myself AFTER I wrote for the patient to "Follow up with Dr. X's wife in his office". I had to write the instructions over, thankfully before they reached the patient.

    Several of my ER colleagues would chart "patiently easily aroused". Hmm what did they do for the patient?

    One chart notation for a surgical consult--the requesting physician made the comment that the surgeon should do "whatever sh*t he felt like doing". I was appalled and had to ask several other people if that was in fact what was written.
  3. by   grace90
    Quote from Rizpah
    "since when do we use tylenol for confusion?" :roll
    Wouldn't it be cool if we could?
  4. by   cheleb61
    I found this in a chart..."pt exfoliated himself. Voiding without difficulty. No bladder distention noted."

    Umm...I though to exfoliate was when you got rid of the dead skin on your body not to remove a foley.
  5. by   Ms Kylee
    I still crack up when I was transcribing hard copy into a patient's chart. The doctor typed in Herniated Dick into the diagnosis field instead of Herniated Disk. My boss proofed my transcription (I was still a fairly new transcriptionist at the time) against the doctor's hard copy and thanked me for correcting the diagnosis, and couldn't stop laughing while she was talking to me.
  6. by   AirforceRN
    Had a diabetic patient with a charted "baloney amputation". I didn't know what to think. Still being a student I was expecting the worst for this poor man.
  7. by   lvs2nrs3535
    Quote from Mistynurse
    I saw this one on a long-term care note: Patient is pleasantly psychotic. :chuckle
    I hope nobody laughs at mine, but they probably will, I recently charted something very similiar!!! patient was pleasantly demented, meaning he was sundowning, his dementia was showing, (sometimes he is A & O X3,), but he was a very happy, cooperative dementia patient!! I have had numerous dementia patients who were not so pleasant!!! I guess I will have to think better how to phrase that one, any suggestions?
    Lol
    KristyBRN
  8. by   Rizpah
    Quote from cheleb61
    I found this in a chart..."pt exfoliated himself. Voiding without difficulty. No bladder distention noted."

    Umm...I though to exfoliate was when you got rid of the dead skin on your body not to remove a foley.
    I gotta remember this one for when it happens at work! LOL
  9. by   Rizpah
    Quote from AirforceRN2b
    Had a diabetic patient with a charted "baloney amputation". I didn't know what to think. Still being a student I was expecting the worst for this poor man.
    OMG! I am SOOO slow - I read this again tonight and finally get it!:trout:
  10. by   jethrobodine
    hey guys, could we have about thirty more posts about that foley catheter stopping the nosebleed?
  11. by   morte
    Quote from Rizpah
    I have a hard time with my new nurse's aides with using correct terminology - instead of saying peri-care or perineum - they often say perinneal care. I don't think we're doing gardening here folks! (and certainly more than just once a year!)
    perineal=pertaining to the perineum
  12. by   Rizpah
    Quote from morte
    perineal=pertaining to the perineum
    my charting blooper! Can't spell - meant to write "perennial", thought something didn't look quite right when I first wrote it. Thanks for the spell check! :chuckle
  13. by   theofficegirl
    During a slow moment last week, a co-worker and I were discussing our parents, and I told her about how my mother (who lives with me) can't seem to remember where things go in the kitchen - for instance, I never know where the large mixing bowl is - it could be in the cabinet with pizza pan and cookie sheets, or it could be in the cabinet with the storage bowls. It's always a hunt.

    Just at the end of this conversation, Doctor came out and handed me a report to be faxed - which read:

    "Patient complains of frequent bowl movements"

    I had to take a moment to compose myself and dry the tears. :roll

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