Charting Bloopers - page 38

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   Jessiedog
    Quote from Gompers
    A classmate in nursing school actually charted, "The patient pooped in his pants."
    Good charting! Short, succinct, and relays the information needed.
  2. by   Jessiedog
    [quote=Aaron86;3140338]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...

    'Pleasantly confused' is perfectly legit!! I've already decided that if I develop Alzheimers, I want to be the confused pt who's right off the planet, but happy and contented. They seem to have so much fun, and are GREAT to work with. Sure makes a change from those who are confused and angry, combative, aggressive, or disressed as a result of their disorientation.
  3. by   talaxandra
    One of my friends says she wants to be intermittantly confused - lovely but dotty with the nice staff and a screaming, painting hell-cat when certain (less favourite) nurses on our ward are caring for her
  4. by   amyb2684
    I was doing a postpartum rotation a couple of weeks ago and my instructor pointed out to me that I charted. "Pt plans on bottle feeding, but will breast feed for benefits of meconium. While in room infant passed colostrum."
  5. by   jayne109
    Quote from AIS52
    or
    on the preop checklist in the belongings section "family took toilet trees home"
    I have to ask-if you pick the toilet tree before the toilets are fully grown, do you get the baby toilets that you find for preschoolers and little kids?
    HE HE HE
  6. by   izeofblu1973
    I always get a kick out of ...pt sleeping but easily arousable. I always want to write, "arent most men?" hehehe. I always write easily awakened.
  7. by   Not_A_Hat_Person
    From a social service note "enjoys music, books, and squirrels in her room." I think they meant watching squirrels (through the window).
  8. by   adoptionacres
    One of our intensivists came to me one day laughing because she'd read this: "Dr. A popped by to see Baby J for a cuddle and a tickle." Another time I wrote in a teenage girls notes: "M engaged in spirited discussion with writer on merits of pink lip gloss over peach." The girl loved it. Don't know what our manager thought. [/quote]

    One shift I had a 3 year old brought in to the ER for a tiny scratch on her elbow after a fall. :icon_roll I wrote the telephone order and charted for "a kiss and a bandaid." Applied and followed by a response of "Patient tolerated well." The review committee loved it.
  9. by   JWaldron
    Quote from HurricaneBreeze
    These aren't charting but still funny...
    When the pts are registered, the registrar enters the admitting diagnoses and most of them aren't versed in medical terminology.

    We have many admitted with "Periferal Vascular Disease"...last week I had a patient with "Flue".

    It always gives me a good chuckle.
    I've seen adm. Dx like this too, and they make me laugh. how about Eurosepsis, or Baloney Amputation, two of my favorites!

    Savvy
  10. by   chellelynn25
    Res is Double AKA ambulates ad-lib throughout facility, tolerates well.
  11. by   smileedee
    The new grad who documented in her initial note the patient had a history of a "cabbage". I just didn't know what to think. Not to mention the very old, experienced male nurse who documented "Patient crapped all night". I kid you not.
  12. by   jessiern
    I recently had a little 98 yr old male patient-cute as a button. A&OX3 all day...until 1845, at which time he proceeds to pull off his gown, out his IV, and go walking down the hall with the cath bag trailing behind. I wrangle him back the room, pop him in a geri-chair, efficently restart the IV, and wheel the chair to the nurses station so I can watch him till his family gets back.

    All done by 1850. I smile to myself about my handling of the sitution as I start documenting the occurance. A fellow nurse asked "what did he do to get put in time out?". I reply, as I cont charting, "he decided to wonder butt-ass naked down the hall". With luck, I realized before I left that as I said that, I also wrote it down in his note. Whoops
  13. by   diane227
    I love having nursing students on my floor. They are fun and I love teaching and interacting with them. But one of them wrote something funny on a chart today. She wrote in her nursing assessment: "Pt. is concerned that he will not be able to pay his hospital bill. He has been referred for financial counseling and is pleased with the outcome" but there was not one word in her assessment about the physical condition of the patient. I made a copy of her note and I thought about writing an addendum to her note: Pt found in cardiac arrest. Pronounced dead at 11:45. Financial counseling no longer needed.

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Charting Bloopers