Charting Bloopers - page 67

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. 6
    Admit orders from the ER written my MD.... Admit pt, dx hypopopotassiumemia???? How about hypokalemia?!?
    And my own error that luckily I caught before I hit save.... mepilex applied to buttcocks!! Oops! Never heard of one of those in A&P!

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  2. 5
    My first semester of nursing school, my clinical-mate's patient's diagnosis was "SICK".
    jsepark119, NancyPie, sharpeimom, and 2 others like this.
  3. 1
    I work in a peds hospital and the patient list will give a brief description of why the patient was admitted. One said "Accidental medication indigestion."
    NancyPie likes this.
  4. 1
    So. I'm taking care of two patients one night - walky talky 20-something post-op floor pt who is only in for a 23 hour obs and an elderly, ICU status lady with multiple cardiac issues.

    During my shift, elderly lady gets made a DNR, has a sixty second run of vtach (totally asymptomatic btw), starts throwing PVCs secondary to a "minor" MI which we then started her on a heparin drip for, and has an acute CHF exacerbation requiring lasix and morphine and a lot of hand-holding.

    I put everything that happened in a single narrative note and forget about it.

    So, early the next morning and towards the end of my shift, the medical student approaches me with this huge, saucer-like eyes and stammers: "So...WHAT all happened with Mr. Jones last night? I was reading the notes and..."

    I'm just glad that it was the medical student who caught my mistake and not someone else!
    DeLanaHarvickWannabe likes this.
  5. 4
    many moons ago, i recall working the night shift and as the shift ended i was on the last of my charting. obviously, i got a little distracted when i charted the following " mr. jones a 52 yr. male c/o of eggs, milk, cherrios, dog food" :uhoh21: needless to say, i was thinking of my grocery list, of course my colleagues never let me live that one down
  6. 3
    a very very tired psych resident's diagnosis... just plain nuts.

    unfortunately, i wasn't working when the attending came in. darn it all!
  7. 2
    Quote from sharpeimom
    a very very tired psych resident's diagnosis... just plain nuts.

    unfortunately, i wasn't working when the attending came in. darn it all!
    having just finished my psych rotation, i'm a firm believer that nanda needs a "coocoo for coco puffs" diagnosis.
    kalycat and nrsang97 like this.
  8. 4
    Another medical chart bloopers."Pt.complaining of headache.Tylenol given as ordered.Checked back with patient one hour later and head gone."
  9. 5
    Here are a few:

    Medical orders and advice:

    May have lollipops orally.

    She is to refrain from sexual intercourse until I see her in the office.

    For his impotence we will discontinue the meds and let his wife handle him.

    MD order: May shower with nurse

    She can begin to use the lawn mower, but no vaginal entrance.
  10. 4
    This isn't a blooper but we have a resident who has doctors orders for "Pats on the back twice a day".
    Nurse J1112, silverbat, hazyblue, and 1 other like this.

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