Charting Bloopers

I was spending a clinical day on a pedi medical floor and was reading through my patient's chart and came across his diagnosis: "short guy syndrome" Me and the other student were stumped as to what this may be so we did a little investigation and it was supposed to be short gut syndrome. We had a good laugh about that one.

Found in the history and physical section:
Patient is on IV D5 1/2NS with Kay Ciel 20 meq/L.

We got a kick outta that one! Oops.

I saw this one in a chart review the other night, "Pt. reports relief from rectal exam per MD"

On an ER flow sheet, "16 Fr foley inserted to pt's L nare." ????????

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.

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.