Charting Bloopers - page 58

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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    Just posting so I can follow this thread. It's a nice change from the usual stuff.
    carolmaccas66 likes this.

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  2. 2
    I am with you. I want to keep up with this thred also! Seriously funny!!!
    carolmaccas66 and GM2RN like this.
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    As a nursing student, I was reviewing for clinicals the following day. I was reading a H & P on a patient from an intern. The intern stated the patient had a TURP in 1995. The patient's a female.
    finn55 and carolmaccas66 like this.
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    Like many of these, this is not exactly a charting blooper...
    My wife and I were in a car accident. We both felt a little sore, so we went to the ED, just to be safe. I got a little confused when they took my wife in for an x-ray, but never did one on me. They car was hit on her side, do I just left it at that and didn't think much about it. Then, when we were d/c'd, we saw that they gave her information about spinal injuries. It didn't make sense. And then it hit me. When they asked about past medical history, she told them that she had a cirvical cerclage (an OB procedure). They heard cirvical and assumed cervical spine. Impressive that they know thier body parts.
    carolmaccas66 likes this.
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    at the end of my third 16 hr.(3p-7a shift) shift in a row I had mistakenly written an exerpt something like this: Res. slept well...stated she had a great night dancing with her husband...
    mind you it was the middle of the night and she was in rehab with a fresh hip and nwb status.:smackingf
  6. 1
    Quote from truebloodRN
    As a nursing student, I was reviewing for clinicals the following day. I was reading a H & P on a patient from an intern. The intern stated the patient had a TURP in 1995. The patient's a female.
    Are you sure the intern didn't say TURB?
    carolmaccas66 likes this.
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    Patient had six litters of fluid drained (That's a lot of kittens!)

    Doctors ED notes, "Vitals stable, BP xxx/xx T xx R xx P 1000.....(What!?!)

    Saying goodnight to patient and she replied "Have a nice vacation" (Will do, I'm out)

    I'll try to find more at work tomorrow night! He He
    carolmaccas66 likes this.
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    Quote from NuteRN
    Like many of these, this is not exactly a charting blooper...
    My wife and I were in a car accident. We both felt a little sore, so we went to the ED, just to be safe. I got a little confused when they took my wife in for an x-ray, but never did one on me. They car was hit on her side, do I just left it at that and didn't think much about it. Then, when we were d/c'd, we saw that they gave her information about spinal injuries. It didn't make sense. And then it hit me. When they asked about past medical history, she told them that she had a cirvical cerclage (an OB procedure). They heard cirvical and assumed cervical spine. Impressive that they know thier body parts.
    I am not sure what you mean by "cirvical cerclage," exactly, but cervical is spelled the same in both areas of the body. What is "cerclage?"
    carolmaccas66 likes this.
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    "What is "cerclage?" Cerclage is a procedure (involves a suture, I believe) used on a pregnant woman with an incompetent cervix. It helps keep the cervix closed until delivery time.
    carolmaccas66 and catshowlady like this.
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    Cerclage: also called purse stings (for slang) because that is what the suture stitch looks like. It is used to keep the cervix closed until it is time for delivery, otherwise if the cervix is not strong enough the baby will be born prematurly.
    carolmaccas66 likes this.


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