Charting Bloopers - page 46

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   blonde1
    here's another for you all- we have an MD that comes in and when he's having a bad day and is mad writes orders like: tell administration to thin chart. or even better: find her ted stockings.
    nicely put, but couldn't you ask us instead of writing such wierd orders
  2. by   BSNBritt
    This was a typo, and was meant to be "Past"

    "Pt. reports pasty abuse"
  3. by   Elsie_kev
    We still kid with the doc that wrote the order "d/c hallucinations" The pharmacy called to tell us it was not on their formulary.
  4. by   dsoginer
    Had to add this one. Working in Well-baby, two residents were writing furiously in a chart and had checked a baby's diaper several times. They finally waved me over and said, "I don't want to alarm you but there is blood in this baby's diaper..." it was all I could do but laugh. In fact it took a minute or so to compose myself to explain uric acid crystals. I left them trying to figure out how to dispose of the charting they had just completed.
  5. by   nursetilly
    This was found in a History & Physical for a surgical patient. It was supposed to say: "Pt has had colitis three times for which she was hospitalized." But the transcription left the "L" out of "colitis". The pt did have three children, so it could be true.
  6. by   nursetilly
    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 sent a specimen to pathology from surgery "portion of ileum"--the technician called me and told me I had spelled it wrong: it is "ilium." I told him "I-l-i-u-m is bone." He said, "Yes, I know." I then said "well, look at the specimen: it's part of the small intestine." He was adament and told me he was going to report me for not knowing my anatomy. I said, go ahead. I never heard anything about it, but never ran into that technician again.
  7. by   nursetilly
    Quote from anonymous1919
    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



    lol
    sooo, what was the dr who did the chole doing near her skene's glands? and what kind of symptoms was she having? on second thought, i don't want to know. :d
  8. by   bigtoms501
    When was in nursing school I was misspelling assess with one less s i was asked buy my instructor what i was doing with my patients a.ses i was teased for months over that lol
  9. by   Wendy RN
    One very tired night nurse once charted on a male patient,

    Patient refused nicotine patch, stated "I do not use that form of birth control".

    I always wondered where you would stick it to prevent pregnancy....LOL
  10. by   NancyPie
    Quote from DutchgirlRN
    Pt telemetry alarm going off at desk repeatedly, pt sleeping w/o any distress noted, telemetry turned off at the desk.

    This patient was found dead during the 0400 v/s. Needless to say, this stupid nurse lost her liscense and the hospital is involved in a lawsuit.
    OMH! OUCH ... wow.... GASP... Dunno what to say....
  11. by   nursenonblonde
    I was a brand new nurse. I had a patient with a very bad burn the entire length of her arm with puss pockets. Unfortunately...I charted...Pt has Pu**y drainage to entire length of arm.......no one noticed but the Dr.
    Last edit by nursenonblonde on Nov 16, '10 : Reason: wrong word
  12. by   sairin8
    Problem list
    Never smoked tobacco
  13. by   nursebellamy
    Although I know this was a transcription error, it still made me laugh. "Pt is hard of hearing and wears bilateral hearing autoimmune deficiency syndromes". Also, in another chart, a doctor had transcribed in his notes something to the effect of ... "...Upon digital insertion into the pt's rectum, tonsils appear to be normal in size and structure." WOW, That is some long finger!!

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Charting Bloopers