Charting Bloopers - page 52

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  dirtyhippiegirl profile page
    1
    So. I'm taking care of two patients one night - walky talky 20-something post-op floor pt who is only in for a 23 hour obs and an elderly, ICU status lady with multiple cardiac issues.

    During my shift, elderly lady gets made a DNR, has a sixty second run of vtach (totally asymptomatic btw), starts throwing PVCs secondary to a "minor" MI which we then started her on a heparin drip for, and has an acute CHF exacerbation requiring lasix and morphine and a lot of hand-holding.

    I put everything that happened in a single narrative note and forget about it.

    So, early the next morning and towards the end of my shift, the medical student approaches me with this huge, saucer-like eyes and stammers: "So...WHAT all happened with Mr. Jones last night? I was reading the notes and..."

    I'm just glad that it was the medical student who caught my mistake and not someone else!
    DeLanaHarvickWannabe likes this.
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  3. Visit  GitanoRN profile page
    4
    many moons ago, i recall working the night shift and as the shift ended i was on the last of my charting. obviously, i got a little distracted when i charted the following " mr. jones a 52 yr. male c/o of eggs, milk, cherrios, dog food" :uhoh21: needless to say, i was thinking of my grocery list, of course my colleagues never let me live that one down
  4. Visit  sharpeimom profile page
    3
    a very very tired psych resident's diagnosis... just plain nuts.

    unfortunately, i wasn't working when the attending came in. darn it all!
  5. Visit  brillohead profile page
    2
    Quote from sharpeimom
    a very very tired psych resident's diagnosis... just plain nuts.

    unfortunately, i wasn't working when the attending came in. darn it all!
    having just finished my psych rotation, i'm a firm believer that nanda needs a "coocoo for coco puffs" diagnosis.
    kalycat and nrsang97 like this.
  6. Visit  CJ NV profile page
    4
    Another medical chart bloopers."Pt.complaining of headache.Tylenol given as ordered.Checked back with patient one hour later and head gone."
  7. Visit  lynhardworkingrn profile page
    5
    Here are a few:

    Medical orders and advice:

    May have lollipops orally.

    She is to refrain from sexual intercourse until I see her in the office.

    For his impotence we will discontinue the meds and let his wife handle him.

    MD order: May shower with nurse

    She can begin to use the lawn mower, but no vaginal entrance.
  8. Visit  CrazierThanYou profile page
    4
    This isn't a blooper but we have a resident who has doctors orders for "Pats on the back twice a day".
    Nurse J1112, silverbat, hazyblue, and 1 other like this.
  9. Visit  GitanoRN profile page
    1
    Quote from CrazierThanYou
    This isn't a blooper but we have a resident who has doctors orders for "Pats on the back twice a day".
    jsepark119 likes this.
  10. Visit  sharpeimom profile page
    2
    My husband had foot/ankle surgery done and a nurse friend shared a charting goof on his chart with me.

    "Change rt. foot and ankle dressing q 12 hours.... rt. AKA on December 12...."

    Just one question. How the heck do you change a foot and ankle dressing on NO foot or ankle?!

    I guess his foot and ankle just spontaneously regenerated.
    nrsang97 and turnforthenurseRN like this.
  11. Visit  GitanoRN profile page
    2
    Quote from sharpeimom
    "

    Just one question. How the heck do you change a foot and ankle dressing on NO foot or ankle?!

    I guess his foot and ankle just spontaneously regenerated.
    Ooops! :uhoh21:
    finn55 and sharpeimom like this.
  12. Visit  FurBabyMom profile page
    2
    Quote from sharpeimom

    Just one question. How the heck do you change a foot and ankle dressing on NO foot or ankle?!
    I guess the same way a bilateral BKA patient has pedal pulses, heels elevated, bilateral knee high scds and teds on and the correct color socks indicating fall risk on their feet. One nurse I used to work with chatted all those...
    nrsang97 and sharpeimom like this.
  13. Visit  amoLucia profile page
    0
    Quote from CrazierThanYou
    This isn't a blooper but we have a resident who has doctors orders for "Pats on the back twice a day".
    I guess he needs burping for an indigestion dx!
  14. Visit  GitanoRN profile page
    0
    LOL


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