Charting Bloopers - page 45

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   truebloodRN
    As a nursing student, I was reviewing for clinicals the following day. I was reading a H & P on a patient from an intern. The intern stated the patient had a TURP in 1995. The patient's a female.
  2. by   NuteRN
    Like many of these, this is not exactly a charting blooper...
    My wife and I were in a car accident. We both felt a little sore, so we went to the ED, just to be safe. I got a little confused when they took my wife in for an x-ray, but never did one on me. They car was hit on her side, do I just left it at that and didn't think much about it. Then, when we were d/c'd, we saw that they gave her information about spinal injuries. It didn't make sense. And then it hit me. When they asked about past medical history, she told them that she had a cirvical cerclage (an OB procedure). They heard cirvical and assumed cervical spine. Impressive that they know thier body parts.
  3. by   blonde1
    at the end of my third 16 hr.(3p-7a shift) shift in a row I had mistakenly written an exerpt something like this: Res. slept well...stated she had a great night dancing with her husband...
    mind you it was the middle of the night and she was in rehab with a fresh hip and nwb status.:smackingf
  4. by   roser13
    Quote from truebloodRN
    As a nursing student, I was reviewing for clinicals the following day. I was reading a H & P on a patient from an intern. The intern stated the patient had a TURP in 1995. The patient's a female.
    Are you sure the intern didn't say TURB?
  5. by   sabrina_RPN
    Patient had six litters of fluid drained (That's a lot of kittens!)

    Doctors ED notes, "Vitals stable, BP xxx/xx T xx R xx P 1000.....(What!?!)

    Saying goodnight to patient and she replied "Have a nice vacation" (Will do, I'm out)

    I'll try to find more at work tomorrow night! He He
  6. by   cherrybreeze
    Quote from NuteRN
    Like many of these, this is not exactly a charting blooper...
    My wife and I were in a car accident. We both felt a little sore, so we went to the ED, just to be safe. I got a little confused when they took my wife in for an x-ray, but never did one on me. They car was hit on her side, do I just left it at that and didn't think much about it. Then, when we were d/c'd, we saw that they gave her information about spinal injuries. It didn't make sense. And then it hit me. When they asked about past medical history, she told them that she had a cirvical cerclage (an OB procedure). They heard cirvical and assumed cervical spine. Impressive that they know thier body parts.
    I am not sure what you mean by "cirvical cerclage," exactly, but cervical is spelled the same in both areas of the body. What is "cerclage?"
  7. by   roser13
    "What is "cerclage?" Cerclage is a procedure (involves a suture, I believe) used on a pregnant woman with an incompetent cervix. It helps keep the cervix closed until delivery time.
  8. by   TonyaM73
    Cerclage: also called purse stings (for slang) because that is what the suture stitch looks like. It is used to keep the cervix closed until it is time for delivery, otherwise if the cervix is not strong enough the baby will be born prematurly.
  9. by   mikata
    From last night, the triage nurse wrote: ROH. According to friend consumed unknown amounts of speed and coke. Responds to pain and alcohol.

    I write my notes in French and don't understand all the abreviations here. I feel I'm missing out on some funny stuff.
  10. by   cherrybreeze
    Quote from roser13
    "What is "cerclage?" Cerclage is a procedure (involves a suture, I believe) used on a pregnant woman with an incompetent cervix. It helps keep the cervix closed until delivery time.
    Quote from TonyaM73
    Cerclage: also called purse stings (for slang) because that is what the suture stitch looks like. It is used to keep the cervix closed until it is time for delivery, otherwise if the cervix is not strong enough the baby will be born prematurly.
    Thank you for the info. I did not know what cerlage was; I haven't ever worked in OB beyond my brief rotation way back in nursing school. I also didn't know what "cirvical" was....
  11. by   tencat
    "7 fecalettes" LOL! What a name for a singing group
  12. by   mr_nurse_drew
    Quote from jkh
    A visiting psychiatrist from India was at rounds one morning when he wrote the following in the patient's note,
    "He is clearly psychotic this morning. He states he has a frog in his throat."

    I'm laughing so hard I'm crying!!!! That's so funny!
  13. by   Streamline2010
    Quote from Terre
    A new intern to our CCU once charted attempts to cardiovert a patient in the following manner:
    Attempted to convert the patient with 200 jews, unsuccessful. Second attempt to convert the patient with 300 jews unsuccessful. Patient finally converted on the third attempt with 300 jews.
    The mental picture of three hundred rabbis surrounding a patient's bed yelling, "Convert, convert!" was too much. We nicknamed him "Call a Code or Call a Rabbi" from that day forward.

    I know that's an old post, but ROTFL!

    Ditto for
    Patient vehemently denies any auditory, tactile, or old factory hallucinations
    Old factory hallucinations : Oh, they are the WORST! All that incessant clanking, and molten metal flows like lava, and dust, and rust, and noxious sulfur vapors, and rain pouring through the holes in the roof, and klaxxons going off, and it's infernally hot in the summer but you have to wear two coats in the winter and... I just KNOW that's what I'm going to have, whenever I finally start losing my mind! Seriously, you'd never want to have old factory hallucinations. Working in an actual old factory for wages is bad enough.
    Last edit by Streamline2010 on Sep 14, '10

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