Charting Bloopers - page 49

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   DixieRedHead
    LOL, just in case anyone wants to know, it's gluteal cleft.
  2. by   just keep swimming
    When reading one of the dictations on a patient with a buttonhole being used for hemodialysis I read, "pt currently using BUTTHOLE on left upper arm AVF". LOL! We were laughing about that one for weeks!
  3. by   nola1202
    Quote from AsatruRN
    "catheter exit site positive for gram positive cock site"

    oh no! seriously? ya gotta watch out for those bad boys!
  4. by   al586
    I'll admit to one of my own charting mistakes....

    The computerized charting in our facility uses a standard assessment form for PT, OT, & Skilled Nursing, so we have to list the department for which we are charting. And, thanks to my mediocre keyboard skills, skilled nursing became:

    "Killed Nursing"

    I'm never going to live that one down....:grn:
  5. by   09LPN
    Best one I have seen:

    "PRN Tylenol deemed effective. Pt no longer suicidal."

    That is great stuff that tylenol!
  6. by   CrazierThanYou
    Yesterday, at the hospital, I was reading a patient's H&P. The following was charted:
    "The patient is homeless, severedly depressed and was talking to his hands. He is incompetent of urine. He was admitted from jail but the reason he was incinerated is unknown."
  7. by   NayRN
    "and secondly, dietary requests do not need to be written by a doc in the orders sheet!"

    Not necessarily...
    When the doc orders "Pt may have 3 beers per day, AC/HS" We should probably have an order for that-especially when the patient is discharged, and we are left with a 12 pack in the nutrition room with no supervision...
  8. by   NayRN
    Quote from traumaboy
    foley's are great for stopping nosebleeds, the balloon works miracles
    And in other uses for foleys- patient in for labor induction had foley bulb inserted to assist in dilating cervix. Patient (not a genius in human anatomy) "What happens when I have to go pee?" (apparently women only have one orifice down there)
  9. by   NayRN
    And then there are the male patients who have the "no" checked on their med history next to "hysterectomy." Whew, that's good to know.
    I always like to test the new admits who seem like know it alls or seekers by asking (males) about hysterectomies and (females) about their prostate health. I am usually right, and it is amazing how many women have severe prostate problems!
  10. by   mr_nurse_drew
    I once read: "Lungs congested. Sound like wind rustling through Autumn leaves." LOL.
  11. by   Not_A_Hat_Person
    Quote from NayRN
    I always like to test the new admits who seem like know it alls or seekers by asking (males) about hysterectomies and (females) about their prostate health. I am usually right, and it is amazing how many women have severe prostate problems!
    When I was in school, 2 or 3 of my patients had grandmothers who died of prostate cancer.
  12. by   GitanoRN
    Quote from crazierthanyou
    yesterday, at the hospital, i was reading a patient's h&p. the following was charted:
    "the patient is homeless, severedly depressed and was talking to his hands. he is incompetent of urine. he was admitted from jail but the reason he was incinerated is unknown."
    lmao
  13. by   sharpeimom
    md note on a psych pt.'s chart: "he doesn't mean to be such an xxx. if he really tried, he could be a lot worse."

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