Charting Bloopers

Res is Double AKA ambulates ad-lib throughout facility, tolerates well.

The new grad who documented in her initial note the patient had a history of a "cabbage". I just didn't know what to think. Not to mention the very old, experienced male nurse who documented "Patient crapped all night". I kid you not.

I recently had a little 98 yr old male patient-cute as a button. A&OX3 all day...until 1845, at which time he proceeds to pull off his gown, out his IV, and go walking down the hall with the cath bag trailing behind. I wrangle him back the room, pop him in a geri-chair, efficently restart the IV, and wheel the chair to the nurses station so I can watch him till his family gets back.

All done by 1850. I smile to myself about my handling of the sitution as I start documenting the occurance. A fellow nurse asked "what did he do to get put in time out?". I reply, as I cont charting, "he decided to wonder butt-ass naked down the hall". With luck, I realized before I left that as I said that, I also wrote it down in his note. Whoops

I love having nursing students on my floor. They are fun and I love teaching and interacting with them. But one of them wrote something funny on a chart today. She wrote in her nursing assessment: "Pt. is concerned that he will not be able to pay his hospital bill. He has been referred for financial counseling and is pleased with the outcome" but there was not one word in her assessment about the physical condition of the patient. I made a copy of her note and I thought about writing an addendum to her note: Pt found in cardiac arrest. Pronounced dead at 11:45. Financial counseling no longer needed.

Now THAT would be hysterical!!!

Got an order from the doc the other day it reads " please do not disturb this resident between the hours of 11pm and 8am, these are her normal sleeping times at home. also serve a glass of warm milk at night."

Really? This resident has a personal alarm, is unsteady at times and confused, but he wants us to leave her alone...hmm.....

gotta love those dictation errors - that's why MD's, PA's, NP's need to check their transcription when they're done!

From my patient's AM notes: "started 15mg oxycodone to elevate pain."

Had an activity order once- OOB to bed, thought that was funny.

I was reading a chart when I came across "pt presents with pu**y drainage". I had to read it more than once before I finally understood what the writer was really saying....