Charting Bloopers

[AHarri66]

Found in the History and Physical section of a patient's chart who had experienced visual hallucinations while ill:

Quote

"Patient vehemently denies any auditory, tactile, or old factory hallucinations."

[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...

[NayRN]

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)

[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!

[mr_nurse_drew, ADN, BSN, RN]

I once read: "Lungs congested. Sound like wind rustling through Autumn leaves." LOL.

[Not_A_Hat_Person, RN]

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.

[GitanoRN, BSN, MSN, RN]

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."

:rotfl: lmao

[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."

[cndn_grl08]

my fav is

"pt pleasantly confused"

and the time one of our male nurses charted that he examined mr smiths lady parts

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...

[CrazierThanYou]

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".

[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.

[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.

[CrazierThanYou]

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. :yelclap: