Charting Bloopers - page 64

by AHarri66 | 462,025 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


  1. 2
    "and secondly, dietary requests do not need to be written by a doc in the orders sheet!"

    Not necessarily...
    When the doc orders "Pt may have 3 beers per day, AC/HS" We should probably have an order for that-especially when the patient is discharged, and we are left with a 12 pack in the nutrition room with no supervision...
    Punkrocksn and Not_A_Hat_Person like this.
  2. 1
    Quote from traumaboy
    foley's are great for stopping nosebleeds, the balloon works miracles
    And in other uses for foleys- patient in for labor induction had foley bulb inserted to assist in dilating cervix. Patient (not a genius in human anatomy) "What happens when I have to go pee?" (apparently women only have one orifice down there)
    Not_A_Hat_Person likes this.
  3. 2
    And then there are the male patients who have the "no" checked on their med history next to "hysterectomy." Whew, that's good to know.
    I always like to test the new admits who seem like know it alls or seekers by asking (males) about hysterectomies and (females) about their prostate health. I am usually right, and it is amazing how many women have severe prostate problems!
    sauconyrunner and sapphire18 like this.
  4. 9
    I once read: "Lungs congested. Sound like wind rustling through Autumn leaves." LOL.
  5. 1
    Quote from NayRN
    I always like to test the new admits who seem like know it alls or seekers by asking (males) about hysterectomies and (females) about their prostate health. I am usually right, and it is amazing how many women have severe prostate problems!
    When I was in school, 2 or 3 of my patients had grandmothers who died of prostate cancer.
    Punkrocksn likes this.
  6. 3
    Quote from crazierthanyou
    yesterday, at the hospital, i was reading a patient's h&p. the following was charted:
    "the patient is homeless, severedly depressed and was talking to his hands. he is incompetent of urine. he was admitted from jail but the reason he was incinerated is unknown."
    lmao
  7. 2
    md note on a psych pt.'s chart: "he doesn't mean to be such an xxx. if he really tried, he could be a lot worse."
    LovedRN and roser13 like this.
  8. 0
    Quote from frustratedRN
    my fav is
    "pt pleasantly confused"


    and the time one of our male nurses charted that he examined mr smiths vagina
    I was taught in school to chart "pleasantly confused", that's not a blooper. Opposed to confused and hitting and screaming, she is pleasant and confused...
  9. 0
    Quote from cndn_grl08
    I was taught in school to chart "pleasantly confused", that's not a blooper. Opposed to confused and hitting and screaming, she is pleasant and confused...
    One I've seen a lot is "pleasantly demented".
  10. 1
    One of my favorites was written by a Canadian physician. He stated that the pt had "fantastic morbid obesity." I understand that technically fantastic means bizarre or unusual, but in the U.S. the word has a positive connotation, usually describing something that is really good. When I read that note, I remember thinking "There is nothing fantastic about that pt's weight!"

    I am also always amused by the doctors' notes that say PERRLA for blind patients & "CV: RRR, no murmurs" on pts w/ A Fib who clearly have an irregular rate or pts w/ very loud, obvious heart murmurs.
    Punkrocksn likes this.


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