Charting Bloopers - page 39

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

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    when I was a medical assistant in an urgent care clinic, I was trying to describe a Pt's cyst which had a thick, odorous d/c, but not knowing the proper term, I wrote "Pt c/o cyst c thick, ***** d/c" as in, it had pus coming out.

    When that was pointed out to me, man I wish we could have used white out!

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  2. 1
    i was working on a opthamology ward 6 years ago and read about the previous nurse's chart saying "admitted a 65yo male.....IVF of 0.9% NS inserted via left eye"
    NancyPie likes this.
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    Hi, new user, just found this website, it's great! Anyway, had to share this story, not a chart blooper, but a huge blooper anyway. Years ago I was an MDS nurse in a SNF and the state was making rounds with one of our (masters prepared!) floor nurses on his med rounds. The nurse noticed the pt needed honey thicked liquids, so he insist (to the inspector with him) that he must go to dietary to get honey to thicken the liqiud!!! needless to say we did not pass inspection that day
    DeLanaHarvickWannabe likes this.
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    I once had an aide point out that I had placed our entire six-bed epilepsy monitoring unit on suicide precautions (check box right above "seizure precautions"). Also transfered an off-service pt to med-surg floor with the final note, "Report called, pt stable, denies pain or nausea, no seizure activity noted." It was all true, though.
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    In rural hospitals we often have to admit our own patients into the computer system. A hospital employee came to the ER with a bite wound after she had, "Interfered in a family fight." The ER RN entered her diagnosis as 'human bite.' When I took over, I knew right away that this was incorrect, but asked anyway, "This is a dog bite, yes?" The patient, who lives alone with her sled dogs, and I both got a good laugh out of that one.
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    OK, one from my early days that my supervisor gave me heck about for months: ABNORMALS: Pt is obese. INTERVENTIONS: Will continue to monitor.

    Yup, she's still obese! :imbar
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    I have thoroughly enjoyed many of these bloopers!! I decided to add one of my own. I had finished filling out a patient's database and gave the chart to his doctor to review. After reading the first page of the database, the doctor turned to me and said, "So Camille, the patient is allergic to a**" I had mistakenly written a** in place of the patient's true allergy to aspirin (asa). Boy, did I about die laughing and so did the doctor!!
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    :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle :chuckle

    During my first year of nursing school, an elderly man coded on a fellow male student while giving him his bath. The student charted, "unable to arouse patient while performing perineal care."
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    Quote from craff1
    ok, this is veterinary (I'm not a nurse yet) the chart for a diabetic cat who was transferred from another hospital said "gave karo syrup, sub Q) The tech's actually tried putting the syrup in a syringe to see if it would squeeze through!! hahaha

    Actually I just heard about this very way of giving karo syrup to a diabetic dog this morning on I believe Good Morning America or the Today show (relaxing due to being snowed in). The suggestion was to put the syrup in a syringe and squirt it between the dog's cheek and teeth so it would run down the back of his throat. However, I admit I do not have any animals so I don't have any first hand experience with this but I wouldn't want to try it.
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    Quote from shannonRN
    just last night i was reading a doctor's h&p...well, the last three words were pleasant octagenarian female?!?!?!?! yes the patient was 88 years old, but a generation every ten years? maybe he meant octadecadarian?!!
    Actually I just had to double check the meaning of octagenarian and if you mean octegenarian (the dictionary can't find octagenarian), octegenarian means in one's eighties. The Merriam Webster dictionary can't find octagedcadarian.

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