Charting Bloopers

I read in a chart "Pt complaining of headache. Tylenol given as ordered. Checked back with pt one hour later and head gone!"
Didn't know Tylenol could take off your head! Yikes!

One of my co-workers said she saw a chart that said "Pt had large bowel movement ambulating around floor!"

Amanda

the other night i was working with one of my best cna's. she had been working doubles for a few days, has two small children and can get a little loopy when sleep deprived. gee, can't we all. she is very sharp, intuitive and conscientous. she walked up to me after her last round, dead serious and started talking to me about one of our residents who has quite a distended abdomen due to various, reasons, ascites, etc. .... she questioned me " do you think that the reason ------';s stomach is so big is because she is compacted?" i made trash jokes the rest of the night.

One time a MD and not a resident wrote this order;
"Bath pt od"

One day I was reviewing a "cardiorespiratory events" record on one of our chronic ventilated patients who had a history of spontaneous desats and bradys. I was quite surprised to see a notation on this patient who has no respiratory drive and is thus totally ventilated at a rate of 30, "pt. apneic for >1 min with sats 70's. Bagged up and resolved in ~30 sec. No assoc. brady" The nurse recording the event had worked in our unit for almost three years at that time. There was nothing in the note to indicate that the kid was disconnected from his vent except when he was being hand-ventilated. I'm just waiting for the day they put this gal in charge...

Then there are the residents who just copy whatever was in the previous note. Some of those errors are humdingers!

This one I found on a LTC note by a nurse:

Pt is pleasantly psychotic.

In our ER patients who do not have a physician are assigned one for admission. We have a rotating call list that we call "Dr. None".
We had a brand new intern who went in to examine a Spanish speaking diabetic with no DR. She kept asking him who his Dr. was and I finally told her, "DR. None".

Next thing I know, she is calling the operator to have DR. NUNN paged!

Just read this little gem in a patient's chart...

"Unfortunately, this young lady had no c-spine..."

I wonder what was holding up her head?

my fav is
"pt pleasantly confused"


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

ok, this is veterinary (I'm not a nurse yet) the chart for a diabetic cat who was transferred from another hospital said "gave karo syrup, sub Q) The tech's actually tried putting the syrup in a syringe to see if it would squeeze through!! hahaha