Charting Bloopers - page 43
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
Jun 4, '10Not strictly a blooper but moderately amusing anyway.
Remember the old observation charts we used to keep at the foot of the patients bed? The ones with temp, BP and so on recorded on them?
One day a patient's daughter came marching over to the nursing station, chart in hand and clearly in high dudgeon. She slammed the chart on the desk and yelled at me "How DARE you write such nasty things about my poor mother?"
Totally nonplussed, as nothing other than observations were ever written in these charts, I asked the lady to point out exactly what it was that had upset her.
She pointed to the column in question and yelled "You people have written that my mother has had BO for five days! Don't you ever WASH your patients?"
I gently explained that "BO" meant "Bowels Opened" NOT "Body Odour" then beat a hasty retreat to the staff room to howl with laughter.
Jun 4, '10Quote from sugoudOne of our residents returned from the hospital just the other day and her discharge papers read "Pt is pleasantly demented".This one I found on a LTC note by a nurse:
Pt is pleasantly psychotic.
She does have dementia but still, it made me think of a psychotic killer on a movie or something.
Jun 4, '10Not a charting blooper but the other night I was having a conversation with a female resident about her recent surgery. She said "I'm going to have to go back to the doctor and have my prostate checked because it is really bothering me". I said "Um ______, women don't have a prostate." She looked at me like I had lost my mind and said very indignantly "Well, when I had my surgery (cholecystectomy) the doctor told me that he would have to be VERY careful of my prostate so he didn't damage it". She is still insisting that she has a prostate and must get it checked ASAP.
Jun 9, '10not a blooper, but the oddest order I have ever seen from an MD read: "No cowboy boots in bed"
I guess the patient (an elderly male) had the habit of wearing his cowboy boots all day AND all night, even in bed, and had developed sores on his feet.
Jun 9, '10Quote from crazierthanyounot a charting blooper but the other night i was having a conversation with a female resident about her recent surgery. she said "i'm going to have to go back to the doctor and have my prostate checked because it is really bothering me". i said "um ______, women don't have a prostate." she looked at me like i had lost my mind and said very indignantly "well, when i had my surgery (cholecystectomy) the doctor told me that he would have to be very careful of my prostate so he didn't damage it". she is still insisting that she has a prostate and must get it checked asap.
in 2002, female paraurethral glands, or [color=#0645ad]skene's glands, were officially renamed the female prostate by the federative international committee on anatomical terminology
Jun 9, '10
Jun 18, '10Quote from Lola77"No cowboy boots in bed"
What's so wrong with that?
Jul 29, '10We had to admit a pt on L&D one night, and she had all of her meds with her. The unit clerk diligently listed all of her meds in the chart. When I reviewed it, she had written, "Pt has side attack in med bag upon admission." Apparently, the nurse was calling out the meds, and the clerk had never heard of Cytotec.
Jul 30, '10I work on a neurosurgical floor. Our population usually will have a back brace or a cervical collar (soft or hard) fitted for use post-op. It is added to the chart whether or not the brace is in the room for the patient. Rather than saying hard cervical collar the secretary was trying to type hard one, what ended up displaying on the chart was "Patient has hard on in room."
Aug 10, '10here's an error i made once after a very bad day, thankfully only on the report sheet for the next shift (and DON, CEO,CFO, ect) and not in the actual charting:
pt: jane doe, A/O/A, smoker since she could hold a cigg, lungs sound like ****.
this is what i normally think in my head but gets automatically translated into proper term (crackles throughout bilat lung fields) w/o any conscious thought, but that day, there was a major break down of communication between my brain and my hand. oops.
Aug 10, '10Here are two pretty funny ones...
We had this patient come in to investigate abdominal pain...After several tests, cultures, and consults, the GI doc reviewed the notes, and wrote`I have no idea what is going on here`... hmmm
Also had this one doc who had horrible handwriting, even by doctors standards...comes in one morning and starts yelling at the charge nurse because a lab he ordered hadnt been done. Well, we had spent a good hour passing his note around, trying to decipher what he had written(it looked like a pretty flower), and finally gave up...the charge nurse shows him the note, and goes `We would love to follow your orders doctor, if you could tell me what this word looks like to you`. The doc checked his note, and answers...`hmm, looks like a flower` Needless to say he forgave us for not following the order lol
Aug 10, '10Quote from brandiashleyhey, you gotta call 'em like you see (hear?) 'em!pt: jane doe, A/O/A, smoker since she could hold a cigg, lungs sound like ****.
Aug 18, '10Dr in to examine wound. Odor present. Dr. Smith present.
I'm not sayin'......but I'm sayin'.