Charting Bloopers - page 61

by AHarri66 456,449 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 young lady was trimming branches when one of the branches flipped up, striking her between the legs. She developed a hematoma of a labia. An OB/GYN excised the hematoma. He was dictating his note and stated,

    "The patient had been struck by a branch between the legs."

    The Medical Transcriptionist had difficulty understanding the statement due to the Physician's thick accent. So she typed,

    "The patient had a stroke on a bridge between two lakes."

    Dave
    Last edit by Davey Do on Nov 25, '10
    0.adamantite, sharpeimom, LouisVRN, and 9 others like this.
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    not a charting problem, but this was the text of an x-ray report: "views of the left elbow were taken which show a third finger pip dorsal dislocation with slight ulnar angulation."

    i wonder exactly how many fingers he had in his elbow?
    carolmaccas66 and roser13 like this.
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    "catheter exit site positive for gram positive cock site"

    0.adamantite, nola1202, LouisVRN, and 3 others like this.
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    I am a home health nurse, I called Med Records to find out what one of my patients had been admitted to the hospital for....the non-medical person who answered the phone informed me that my patient had been admitted for hyperchlamydia. Stunned by this as my patient was not really someone who would have this nor would they have a HYPER version, I asked her to spell it for me....she spelled H-Y-P-E-R-C-A-L-C-E-M-I-A. Laughing I said ok thanks but that is hypercalcemia, much different from hyperchlamydia....
    0.adamantite, carolmaccas66, and pca_85 like this.
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    In nursing school, one of my fellow students wrote that a patient had a pulse grade of 2 for his posterior tib and pedal pulses. Too bad the patient had both of his legs amputated many years before he was on the unit...whoops. And here's your sign.
    noreenl, carolmaccas66, and silverbat like this.
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    Quote from FC RN BSN
    In nursing school, one of my fellow students wrote that a patient had a pulse grade of 2 for his posterior tib and pedal pulses. Too bad the patient had both of his legs amputated many years before he was on the unit...whoops. And here's your sign.

    I've seen charting errors like this one done many times, and not by students but experienced RN's....scary, huh?
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    Quote from crissrn27
    Hi, new user, just found this website, it's great! Anyway, had to share this story, not a chart blooper, but a huge blooper anyway. Years ago I was an MDS nurse in a SNF and the state was making rounds with one of our (masters prepared!) floor nurses on his med rounds. The nurse noticed the pt needed honey thicked liquids, so he insist (to the inspector with him) that he must go to dietary to get honey to thicken the liqiud!!! needless to say we did not pass inspection that day
    ha-ha
    carolmaccas66 and silverbat like this.
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    these aren't charting bloopers-- but I work in ER, and working triage quite often, I'd like to type just what the patient tells me.
    Examples: 80-ish yr old woman tells me she saw blood in the toilet but she didn't have a bowel movement so she doesn't know if it came from her rectum or her "majina" "janiva" "whatever its called" hahahah!! she was so cute.
    "I have fibronalgia and its acting up"
    "I think my prostrate is enlarged" (hear that allllll the time)
    "I was out in the sun yesterday and now my face is swollen and I'm afraid my throats gonna swell shut" now correct me if I'm wrong, but I really can't see that one happening!???


    A girl I used to work with was joking around and typed in " I am a sl*t and I like to ***unrepeatable*****" and was showing it to another nurse and accidently hit file! We can "undo" documentation but it still shows up in the chart, just has "undone" after it!!! Ahhh, watch what you say!

    I work nights and it can get pretty hairy after working a few in a row. One RN actually started typing about her dreams!! Fortunately she woke up and erased it!! I find myself writing about what people at the desk are talking about when I'm tired. Happens to us all! I'll often call report to the floor and go, oops, I charted that the IV is in the LAC, but really, its in the RAC. (dyslexic maybe?)

    And my personal pet peeve is one nurse who's first nursing note is the SAME for every patient, no matter what the heck is going on with them. "resting in bed, resps easy nonlabored lungs clear abd soft nontender skin fleshtone dry alert and oriented." Just like that, no punctuation, etc. His assessment then reads "unconscious... or rhonchi heard throughout, etc" HELLO?! Try to defend all that in court.
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    Quote from rzookrn;
    I work nights and it can get pretty hairy after working a few in a row. One RN actually started typing about her dreams!! Fortunately she woke up and erased it!! I find myself writing about what people at the desk are talking about when I'm tired. Happens to us all!
    A friend fell asleep while writing her notes and woke up to find she'd written "I know that you can see me"!
  10. 1
    Quote from Zee_RN
    ...in an H&P...."hx of vaginal hysterectomy for hemorroids."

    Oh yeah?
    Hey, no fair, my hysterectomy didn't take care of my hemorroids!
    carolmaccas66 likes this.


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