Charting Bloopers - page 50

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  cndn_grl08} profile page
    0
    Quote from frustratedRN
    my fav is
    "pt pleasantly confused"


    and the time one of our male nurses charted that he examined mr smiths vagina
    I was taught in school to chart "pleasantly confused", that's not a blooper. Opposed to confused and hitting and screaming, she is pleasant and confused...
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  3. Visit  CrazierThanYou} profile page
    0
    Quote from cndn_grl08
    I was taught in school to chart "pleasantly confused", that's not a blooper. Opposed to confused and hitting and screaming, she is pleasant and confused...
    One I've seen a lot is "pleasantly demented".
  4. Visit  RURN2O11} profile page
    1
    One of my favorites was written by a Canadian physician. He stated that the pt had "fantastic morbid obesity." I understand that technically fantastic means bizarre or unusual, but in the U.S. the word has a positive connotation, usually describing something that is really good. When I read that note, I remember thinking "There is nothing fantastic about that pt's weight!"

    I am also always amused by the doctors' notes that say PERRLA for blind patients & "CV: RRR, no murmurs" on pts w/ A Fib who clearly have an irregular rate or pts w/ very loud, obvious heart murmurs.
    Punkrocksn likes this.
  5. Visit  RURN2O11} profile page
    1
    I once saw a pap smear ordered on a man. Does that actually exist somewhere? I thought it was pretty hilarious. And, no, the pt was not a transvestite or a hermaphrodite.
    Punkrocksn likes this.
  6. Visit  CrazierThanYou} profile page
    0
    Quote from RURN2O11
    One of my favorites was written by a Canadian physician. He stated that the pt had "fantastic morbid obesity." I understand that technically fantastic means bizarre or unusual, but in the U.S. the word has a positive connotation, usually describing something that is really good. When I read that note, I remember thinking "There is nothing fantastic about that pt's weight!"

    I am also always amused by the doctors' notes that say PERRLA for blind patients & "CV: RRR, no murmurs" on pts w/ A Fib who clearly have an irregular rate or pts w/ very loud, obvious heart murmurs.
    I giggled.
  7. Visit  Punkrocksn} profile page
    0
    lmao, I was about to say something then realized you were talking about NICU baaa ha hahha!
  8. Visit  Punkrocksn} profile page
    4
    A fellow student was watching her first woundvac on her patient with WCN. Before wound care left, she asked if the student had any questions. The student says, "I noticed something in her perineal area... I don't know how to describe it... CORAL?"
    The patient had external HEMORRHOIDS
  9. Visit  Jtsqueek} profile page
    4
    How about " patient is on continuous Lasix infusion running at .... And has an indoor pool" in my defense it was about 2am :-)
    0.adamantite, LovedRN, sauconyrunner, and 1 other like this.
  10. Visit  NancyPie} profile page
    0
    Quote from NurseMonkey
    I work in a facility that has recruited nurses from puerto rico to staff the building. Most of them speak little or no english, and as you can imagine the charting is quite difficult to make sense of. I think the most memorable thing I saw was a pharmacy return sheet where the reason for return of meds simply said "PT DEAD"
    Working in a nursing home, I've had to return meds for this reason. I always write Patient discharged. At least she was clear? x'D
  11. Visit  GM2RN} profile page
    0
    Quote from RURN2O11
    I once saw a pap smear ordered on a man. Does that actually exist somewhere? I thought it was pretty hilarious. And, no, the pt was not a transvestite or a hermaphrodite.
    We get this occasionally in the ER with computer charting. The docs have order sets to choose from and will sometimes forget to uncheck the urine pregnancy test for males.
    Last edit by GM2RN on May 4, '12 : Reason: to quote OP
  12. Visit  Kay28} profile page
    3
    Here's my favorite I saw yesterday. I had a patient who had a transvaginal ultrasound. The radiologists impression was, "No testicular torsion."
    nrsang97, sethmctenn, and Punkrocksn like this.
  13. Visit  DeLanaHarvickWannabe} profile page
    1
    We had a patient who required an MRI, but had nipple rings of the bar variety that I guess hadn't been removed in some time. Well, she couldn't get them out and wasn't interested in having any of us try. The physician, who is a personal friend of mine, was trying his darndest to get her to go through with it. He wrote "discussed with patient the merits of removing nipple jewelry."

    Not a blooper because, well, that's what he meant, but it was still hilarious. We did get them out with pliers, by the way. She was actually a pretty cool older (yes, older!) gal. She had absolutely beautiful tattoos and her husband smoked pot to chill out with their adult son.
    Punkrocksn likes this.
  14. Visit  Krissy,RN} profile page
    0
    H&P describing a vaginal exam and pap...Patient....a 2 year old boy??


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