Charting Bloopers - page 57

by AHarri66 455,097 Views | 733 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

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    A patient was being stubborn about getting up from the bed and walking 5xqd 1st day post-op, and the note that was written by the nurse was this:

    "Pt states at home that she is usually sedimentary and doesn't need to walk today."

    Hmm....the patient is usually rocky??
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    At handover today, the staff member going off shift said "[pt's name] complained of cockroach". The then thought about it for a moment and said, "oh wait, it could be earache"
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    As a CNA, reading some of these posts I'm glad we're not allowed to note in the pt's chart. That way I can't be blamed for confusing CBI with hooking IV to F/C! That's a pretty embarrassing error, not to mention dangerous if it were actually done.
    carolmaccas66 likes this.
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    On a psych ward I once read notes of a collegue stating;

    Patient challanged me to game of chess, I accepted and beat him. Patient stated this was first time he'd ever been beat. PLAN: encourage patient to play more chess as part of rehab.

    Couldn't stop laughing at this

    Although not written a collegue of mine has often described a patient as 'Mad as a box of frogs' durign handover.... God I love psychiatry.
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    Not a blooper (as it's obviously deliberate....), but we have an RN on my floor who puts smiley faces in her assessments..... LOL
    carolmaccas66 likes this.
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    "the patient developed severe, 10/10, epigastric abdominal pain, which persists today. This was associated with nausea and vomiting of undigested food, which he states he ingested approximately 2 days later. "

    carolmaccas66, rzookrn, and Davey Do like this.
  7. 1
    Oh, november17 - I hope that's a charting blooper rather than reportage, but I can't imagine what it should have been...
    carolmaccas66 likes this.
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    Quote from talaxandra
    Oh, november17 - I hope that's a charting blooper rather than reportage, but I can't imagine what it should have been...
    It was supposed to say "two days before"
    carolmaccas66 likes this.
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    That's considerably less distressing
    carolmaccas66 likes this.
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    My sister is a NICU nurse and was asked to help with a difficult birth at the end of her third 12 hour night shift in a row. When she was ready to leave, she reported to the NP, she told her that she gave the baby a blow job. What she meant to say was blow-by oxygen. She still gets teased about this, two months after the slipup.

    I hate to bring this up, but I was taught that the singular form of "nares" is "naris" instead of "nare." Not trying to be uppity or anything, just thought I'd throw that in there.