Charting Bloopers - page 35

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   arual56
    Quote from cmggriff
    I saw this one in a chart review the other night, "Pt. reports relief from rectal exam per MD"
    Yuck! A mental image I REALLY don't want stuck in my head.
  2. by   arual56
    Quote from janine3&5
    On an ER flow sheet, "16 Fr foley inserted to pt's L nare." ????????
    This one I could actually see happening if the doctor was using the balloon to apply pressure to a bleeder. God, I hope that was what was going on. I would hate to hear that there was like 200ml of clear yellow urine returned.
  3. by   chelseaxyrene
    w/ o2 cannula attached to uro bag...
  4. by   NewWayofLife
    Just the other night, in an H&P on a hip fx:

    "Patient is allergic to Percocet, Tylenol #3, and Darvocet. All those medications caused goofy."

    A- that's not an allergy, that's a side effect
    B- if those meds "caused goofy"- what caused Mickey and Pluto?

    "Fall: The differential diagnosis is mechanical vs. syncope. Since patient is not unconcious, syncope unlikely."

    Sure, doc, cause no one could ever pass out and fall, then come to in the 8 hours between when he fell and when you dictated this?

    To his credit, english wasn't this doc's first language.
  5. by   Aaron86
    Quote from frustratedRN
    my fav is
    "pt pleasantly confused"


    and the time one of our male nurses charted that he examined mr smiths vagina

    I wonder if "pleasantly confused" is a legitimate description. I have also seen this on multiple LTC charts, i thought it was funny at first but then I began to wonder...

    By the way everyone, keep the hilarity coming! I laughed so hard on some of these I think I might have strained something.
  6. by   nursemike
    Quote from Aaron86
    I wonder if "pleasantly confused" is a legitimate description. I have also seen this on multiple LTC charts, i thought it was funny at first but then I began to wonder...

    By the way everyone, keep the hilarity coming! I laughed so hard on some of these I think I might have strained something.
    Sorry to get serious--it's so unlike me--but you raise a fair question. I've used that expression, at times, but is it legit? Some patients are surely more "pleasantly" confused to the staff--cute and funny, as opposed to confused and agitated or confused and combative. But it does at least appear that some confused patients are in a happier alternate reality than others. But it's worth remembering that pleasantly confused can turn to fearful rather quickly. I'm thinking of a lady who thought her television was a window and was enjoying watching all of the horses running in the yard, but then was alarmed by a close-up of Audie Murphy and thought he was a peeping-tom.
    Still, she was a happy little 90 y.o. girl again in a few minutes. I guess if you have to be confused, it's better to be happy.
  7. by   bassandtea
    From one of my friends "Diagnosis: Sick" That's all that was written... Sick with what?
  8. by   aKyRN81
    Quote from nursemike
    Sorry to get serious--it's so unlike me--but you raise a fair question. I've used that expression, at times, but is it legit? Some patients are surely more "pleasantly" confused to the staff--cute and funny, as opposed to confused and agitated or confused and combative. But it does at least appear that some confused patients are in a happier alternate reality than others. But it's worth remembering that pleasantly confused can turn to fearful rather quickly. I'm thinking of a lady who thought her television was a window and was enjoying watching all of the horses running in the yard, but then was alarmed by a close-up of Audie Murphy and thought he was a peeping-tom.
    Still, she was a happy little 90 y.o. girl again in a few minutes. I guess if you have to be confused, it's better to be happy.
    The term 'pleasantly confused' has been in use for ages and means exactly what you describe. The patient is not distressed, fearful, or hostile in regards to their confused status. It's not a diagnosis, just a description of current state of mind.
  9. by   faline1973
    Before he dictated, one of our cardiologists stated "That woman is NUTS. Absolutely crazy. She hops from hospital to hospital. We've done every possible test on her and there is nothing wrong. She's taking 200 mg of aldactone a day. It is scientifically impossible for her to be hypokalemic unless she's taking a diuretic and she swears she isn't. She is CRAZY and I'm putting that in my dictation!

    Sure enough... he wrote "Unsure if patient has mental problems with an anatomical reason such as deteriorating white matter or is intentionally trying to confound her physicians."
    :chuckle
  10. by   mangosteen
    What about new factory hullicinations? ha ha.
  11. by   texas2007
    One of our admitting diagnoses is "Full term neonate with major problems". OK then...Have seen it on multiple charts...
  12. by   beachmom
    My friend's gramdma had a reaction to Demerol. The doctor wrote in large letters:
    DEMERAL = CRAZY

    Several times I have seen doctors write "foley to gravity"
    What other kind is there? Put in a foley to suction?
  13. by   ElvishDNP
    Quote from beachmom
    Several times I have seen doctors write "foley to gravity"What other kind is there? Put in a foley to suction?
    For bladder retraining purposes, you can put a foley in to intermittent drainage.

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