Charting Bloopers - pg.5 | allnurses

Charting Bloopers - page 5

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. Visit  sandigapeachlpn profile page
    the other night i was working with one of my best cna's. she had been working doubles for a few days, has two small children and can get a little loopy when sleep deprived. gee, can't we all. she is very sharp, intuitive and conscientous. she walked up to me after her last round, dead serious and started talking to me about one of our residents who has quite a distended abdomen due to various, reasons, ascites, etc. .... she questioned me " do you think that the reason ------';s stomach is so big is because she is compacted?" i made trash jokes the rest of the night.
  2. Visit  nosilanurse profile page
    One time a MD and not a resident wrote this order;
    "Bath pt od"
  3. Visit  NotReady4PrimeTime profile page
    One day I was reviewing a "cardiorespiratory events" record on one of our chronic ventilated patients who had a history of spontaneous desats and bradys. I was quite surprised to see a notation on this patient who has no respiratory drive and is thus totally ventilated at a rate of 30, "pt. apneic for >1 min with sats 70's. Bagged up and resolved in ~30 sec. No assoc. brady" The nurse recording the event had worked in our unit for almost three years at that time. There was nothing in the note to indicate that the kid was disconnected from his vent except when he was being hand-ventilated. I'm just waiting for the day they put this gal in charge...

    Then there are the residents who just copy whatever was in the previous note. Some of those errors are humdingers!
    Last edit by NotReady4PrimeTime on Sep 5, '01
    carolmaccas66 likes this.
  4. Visit  sugoud profile page
    This one I found on a LTC note by a nurse:

    Pt is pleasantly psychotic.
    verene, SomedaySoonNY, silverbat, and 7 others like this.
  5. Visit  ok-rn profile page
    In our ER patients who do not have a physician are assigned one for admission. We have a rotating call list that we call "Dr. None".
    We had a brand new intern who went in to examine a Spanish speaking diabetic with no DR. She kept asking him who his Dr. was and I finally told her, "DR. None".

    Next thing I know, she is calling the operator to have DR. NUNN paged!
    CrazyGoonRN and carolmaccas66 like this.
  6. Visit  NotReady4PrimeTime profile page
    Just read this little gem in a patient's chart...

    "Unfortunately, this young lady had no c-spine..."

    I wonder what was holding up her head?
  7. Visit  frustratedRN profile page
    my fav is
    "pt pleasantly confused"

    and the time one of our male nurses charted that he examined mr smiths vagina
  8. Visit  craff1 profile page
    ok, this is veterinary (I'm not a nurse yet) the chart for a diabetic cat who was transferred from another hospital said "gave karo syrup, sub Q) The tech's actually tried putting the syrup in a syringe to see if it would squeeze through!! hahaha
    sharpeimom, carolmaccas66, and yooperPN like this.
  9. Visit  ToofunnyRN profile page
    During Halloween at our childrens hospital, each unit decorates pumpkins using that units theme. We also let the kids decorate them and take them to their rooms. After awhile they start to rot. I had a MD come in and write an order to bath patient stat!
    CrazyGoonRN and carolmaccas66 like this.
  10. Visit  mgthompson profile page
    Transcribed dictation is a constant source of hilarity for me.. on the OB floor: "Gross fecal movement noted" (the doc said "fetal").. or on vaginal exam: "small bloody shell" (that would be "show" - I haven't seen one hatch yet.. )
  11. Visit  kaycee profile page
    One of my co-workers wrote this in her triage assessment the other day.

    Patient is illegally blind.

  12. Visit  panda_181 profile page
    I read these and always laughed my head off at some of these, and this weekend I found some of my own!

    I was reading 2 dictations from consultations from 2 different doctors. One was about "a very pleasant lady sitting down and in no apparent distress". Now, does this mean that she's cranky when she's standing or lying? I'm not quite sure...

    And the other was about a child, whose symptoms of autism are "moderately severe". Can you put those 2 words in the same sentence? I thought it had to be one or the other...but maybe that's just me...

    carolmaccas66 likes this.
  13. Visit  SweetnesssssRN profile page
    a nurse copied the admit orders for a pt with a foley and she added: INPUT & OUTPUT
    she later told me: "I think i've been spending too much time on the computer"