Charting Bloopers - page 55

by AHarri66

398,560 Views | 718 Comments

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 hallucinations." YIKES! Angela... Read More


  1. 2
    I work with a nurse who collects hilarious charting bloopers. When I find one, I put a copy of it in her mailbox (with the patient's name and other ID info blacked out) for her. She does the same for me because she knows it always brightens my day.

    The most recent one: under drug allergies, the patient had listed CARDIZEM because the reaction was "Makes me feel crappy".
    Apparently not too crappy, because the patient was on a cardizem drip.
  2. 5
    On computer charting I caught this before I saved my note and was able to correct it:

    Client has a large *ss on left posterior thigh.

    Thank goodness I was able to change that to "mass"!

    When I worked in a hospital I would always find "pedal pulses strong" on bil BKA's or VS charted on patients that had expired hours before, or bil lung sounds clear on a pulmonectomy client. Amazing!
  3. 3
    Quote from Green Nurse
    On computer charting I caught this before I saved my note and was able to correct it:

    Client has a large *ss on left posterior thigh.

    Thank goodness I was able to change that to "mass"!

    When I worked in a hospital I would always find "pedal pulses strong" on bil BKA's or VS charted on patients that had expired hours before, or bil lung sounds clear on a pulmonectomy client. Amazing!
    Your post reminded me of the time I got 'corrected' for a data entry I DIDN'T make - and it would have been pretty strange if I had. I had a patient who was a left BKA and a right AKA, and I didn't enter a height for him! Should I have entered his current height? On his right side or on his left? Or his reported height before the first surgery, or before the second? (I just got a dirty look when I asked )

    Savvy
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  5. 3
    on an OB addmission assessment while i was doing my maternity rotation for RN school i came across this:

    Pain scale: 8 Location: Husband.....

    Me, my fellow classmates, instructor, and the staff nurses laughed for a good 5 min on this one..
  6. 4
    ER admitting diagnosis: "SICK"
    Must have been a busy day.
  7. 5
    Not strictly a blooper but moderately amusing anyway.

    Remember the old observation charts we used to keep at the foot of the patients bed? The ones with temp, BP and so on recorded on them?

    One day a patient's daughter came marching over to the nursing station, chart in hand and clearly in high dudgeon. She slammed the chart on the desk and yelled at me "How DARE you write such nasty things about my poor mother?"

    Totally nonplussed, as nothing other than observations were ever written in these charts, I asked the lady to point out exactly what it was that had upset her.

    She pointed to the column in question and yelled "You people have written that my mother has had BO for five days! Don't you ever WASH your patients?"

    I gently explained that "BO" meant "Bowels Opened" NOT "Body Odour" then beat a hasty retreat to the staff room to howl with laughter.
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    Quote from sugoud
    This one I found on a LTC note by a nurse:

    Pt is pleasantly psychotic.
    One of our residents returned from the hospital just the other day and her discharge papers read "Pt is pleasantly demented".

    She does have dementia but still, it made me think of a psychotic killer on a movie or something.
  9. 1
    Not a charting blooper but the other night I was having a conversation with a female resident about her recent surgery. She said "I'm going to have to go back to the doctor and have my prostate checked because it is really bothering me". I said "Um ______, women don't have a prostate." She looked at me like I had lost my mind and said very indignantly "Well, when I had my surgery (cholecystectomy) the doctor told me that he would have to be VERY careful of my prostate so he didn't damage it". She is still insisting that she has a prostate and must get it checked ASAP.
    carolmaccas66 likes this.
  10. 2
    not a blooper, but the oddest order I have ever seen from an MD read: "No cowboy boots in bed"

    I guess the patient (an elderly male) had the habit of wearing his cowboy boots all day AND all night, even in bed, and had developed sores on his feet.


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