Charting Bloopers - page 57

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  gwstudent profile page
    1
    That transcriptionist needs to be fired.....lol
    GM2RN likes this.
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  3. Visit  katmarieRN profile page
    5
    "Wound irrigated with litters and litters of worm saline"

    Op note for abdominal washout.
    sharpeimom, GM2RN, skylark, and 2 others like this.
  4. Visit  WesRN profile page
    3
    Progress note read: Resident continues to C/O severe lower back pain after fall this AM. PCP notified and orders given for x-ray to her scrotum.
    GM2RN, sharpeimom, and Christy1019 like this.
  5. Visit  tumbleweedlvn profile page
    1
    Oh I have a great one....we had a pt. on abx for a staph infection in his penis. We still used paper charting and at the end of a VERY long day, while trying to quickly chart before my shift ended, I charted "Pt. continues on abx for staff to penis" of course you can only put 1 line through the mistake so everyone got a good laugh. LOL
    SomedaySoonNY likes this.
  6. Visit  brrn76 profile page
    1
    Have seen one ER note say "wound is red and *****" (No wonder they invented the word purulent). Had another where doc wrote time, including the seconds, on his note after being told numerous times to date and time his orders. Last one is my favorite, doc wrote progress note on patient that said "Said hi" "She feels better today". !!
    xoemmylouox likes this.
  7. Visit  lovely72 profile page
    6
    Patient walks in to GYN clinic and refuses any contraceptive methods stating "I do not have sexual intercourse, I have outercourse".
    silverbat, JeanettePNP, xoemmylouox, and 3 others like this.
  8. Visit  MonMac profile page
    6
    I've been collecting these for 10 years.
    Actual writings from Charts in a Hospital: .

    1. The patient refused autopsy.

    2. The patient has no previous history of suicides.

    3. Patient has left white blood cells at another hospital.

    4. She has no rigors or shaking chills, but her husband states she was very
    hot in bed last night.

    5. Patient has chest pain if she lies on her left side for over a year.

    6. On the second day the knee was better, and on the third day it disappeared.

    7. The patient is tearful and crying constantly. She also appears to be depressed.

    8. The patient has been depressed since she began seeing me in 1993.

    9. Discharge status: Alive but without my permission

    10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.

    11. Patient had waffles for breakfast and anorexia for lunch.

    12. She is numb from her toes down.

    13. While in ER, she was examined, x-rated and sent home.

    14. The skin was moist and dry.

    15. Occasional, constant infrequent headaches.

    16. Patient was alert and unresponsive.

    17. Rectal examination revealed a normal size thyroid.

    18. She stated that she had been constipated for most of her life, until she
    got a divorce.

    19. I saw your patient today, who is still under our car for physical therapy.

    20. Both breasts are equal and reactive to light and accommodation.

    21. Examination of genitalia reveals that he is circus sized.

    22. The lab test indicated abnormal lover function.

    23. Skin: somewhat pale but present.

    24. The pelvic exam will be done later on the floor.

    25. Patient has two teenage children, but no other abnormalities.

    hope you enjoy them as much as I did
    silverbat, scaredsilly, Karou, and 3 others like this.
  9. Visit  xoemmylouox profile page
    3
    My favorites of the day are from the same pt's chart: Patient has previous diagnosis of Assburgers. Patient's Assburgers had not previously not been an issue with employers, but is seeming to impact his current position.

    * I must add that this is not a dictation where someone misunderstood the intent of the word. This is how someone actually spells this term.
    Last edit by xoemmylouox on Dec 30, '14 : Reason: Clarification
  10. Visit  sharpeimom profile page
    2
    I just have one quick question, please. If I want a quick meal, which fast food joint serves xxx burgers?

    I'm sorry, but I just couldn't resist. My poor mother tried sooo hard to rear a lady.
    nrsang97 and xoemmylouox like this.
  11. Visit  Rose_Queen profile page
    2
    Quote from xoemmylouox
    My favorites of the day are from the same pt's chart: Patient has previous diagnosis of Assburgers. Patient's Assburgers had not previously not been an issue with employers, but is seeming to impact his current position.

    * I must add that this is not a dictation where someone misunderstood the intent of the word. This is how someone actually spells this term.
    I'm mildly curious about the eating habits of that person…
    Last edit by Rose_Queen on Dec 30, '14 : Reason: add quote
    sharpeimom and xoemmylouox like this.
  12. Visit  OneDuckyRN profile page
    5
    Not nearly as funny as many of the others I've read here, but here goes...

    Read in a pt's progress note: "The pt appears to be more alert when awake."  Um, yeah!

    Well, it was funny to me at about 0500 during a very busy shift!
    JeanettePNP, A&Ox6, schnookimz, and 2 others like this.
  13. Visit  BostonFNP profile page
    0
    Just saw a pt today for ED follow-up. ED doc very worried about: "a region of flatulence on patient's coccyx".


    Sent from my iPhone.
  14. Visit  schnookimz profile page
    0
    Quote from BrandonLPN
    another one:

    a foreign RN I work with documented "resident has pusy drainage from penis"

    But... she hasn't yet mastered English spelling, and the word "pusy" had an extra 's'....
    Hahaha I used to work at a doctors office and one of the schedulers made the same mistake!!! Schedule stated patient was coming in for "pusy finger" ---again, I left out the S that the scheduler did not leave out!!!

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