Charting Bloopers - page 67
by AHarri66 414,160 Views | 726 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
- 6Aug 5, '12 by FLICURNAdmit 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!
- 1Aug 9, '12 by dirtyhippiegirlSo. 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!
- 4Aug 9, '12 by GitanoRN Guidemany 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
- 1Aug 10, '12 by brilloheadQuote from sharpeimomhaving just finished my psych rotation, i'm a firm believer that nanda needs a "coocoo for coco puffs" diagnosis.a very very tired psych resident's diagnosis... just plain nuts.
unfortunately, i wasn't working when the attending came in. darn it all!
- 5Aug 26, '12 by lynhardworkingrnHere 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.