Charting Bloopers - page 65
by AHarri66 455,516 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
- 0Apr 27, '12 by CrazierThanYouQuote from RURN2O11I giggled.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.
- 4Apr 28, '12 by PunkrocksnA fellow student was watching her first woundvac on her patient with WCN. Before wound care left, she asked if the student had any questions. The student says, "I noticed something in her perineal area... I don't know how to describe it... CORAL?"
The patient had external HEMORRHOIDS
- 0May 3, '12 by NancyPieQuote from NurseMonkeyWorking in a nursing home, I've had to return meds for this reason. I always write Patient discharged. At least she was clear? x'DI work in a facility that has recruited nurses from puerto rico to staff the building. Most of them speak little or no english, and as you can imagine the charting is quite difficult to make sense of. I think the most memorable thing I saw was a pharmacy return sheet where the reason for return of meds simply said "PT DEAD"
- 0May 4, '12 by GM2RNQuote from RURN2O11We get this occasionally in the ER with computer charting. The docs have order sets to choose from and will sometimes forget to uncheck the urine pregnancy test for males.I once saw a pap smear ordered on a man. Does that actually exist somewhere? I thought it was pretty hilarious. And, no, the pt was not a transvestite or a hermaphrodite.Last edit by GM2RN on May 4, '12 : Reason: to quote OP
- 1May 7, '12 by DeLanaHarvickWannabeWe had a patient who required an MRI, but had nipple rings of the bar variety that I guess hadn't been removed in some time. Well, she couldn't get them out and wasn't interested in having any of us try. The physician, who is a personal friend of mine, was trying his darndest to get her to go through with it. He wrote "discussed with patient the merits of removing nipple jewelry."
Not a blooper because, well, that's what he meant, but it was still hilarious. We did get them out with pliers, by the way. She was actually a pretty cool older (yes, older!) gal. She had absolutely beautiful tattoos and her husband smoked pot to chill out with their adult son.