Charting Bloopers - page 7

by AHarri66

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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
    During Halloween at our childrens hospital, each unit decorates pumpkins using that units theme. We also let the kids decorate them and take them to their rooms. After awhile they start to rot. I had a MD come in and write an order to bath patient stat!
    CrazyGoonRN and carolmaccas66 like this.
  2. 4
    Transcribed dictation is a constant source of hilarity for me.. on the OB floor: "Gross fecal movement noted" (the doc said "fetal").. or on vaginal exam: "small bloody shell" (that would be "show" - I haven't seen one hatch yet.. )
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    One of my co-workers wrote this in her triage assessment the other day.

    Patient is illegally blind.

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    I read these and always laughed my head off at some of these, and this weekend I found some of my own!

    I was reading 2 dictations from consultations from 2 different doctors. One was about "a very pleasant lady sitting down and in no apparent distress". Now, does this mean that she's cranky when she's standing or lying? I'm not quite sure...

    And the other was about a child, whose symptoms of autism are "moderately severe". Can you put those 2 words in the same sentence? I thought it had to be one or the other...but maybe that's just me...

    Amanda
    carolmaccas66 likes this.
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    a nurse copied the admit orders for a pt with a foley and she added: INPUT & OUTPUT
    she later told me: "I think i've been spending too much time on the computer"
  6. 2
    hilarious thread. keep em coming!!!

    i used to work on a rehab unit and we had an 18 year old with head injuries from a mva. well, he had decorticate posturing. one of the psychiatrists wrote that the patient had "rabbit syndrome!"
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    I review charts and come across bloopers quite often. Some of my most recent:

    60 y.o. male with known cirrhosis and portable HTN.

    Family decided on a no code stasis and thought it was time to discuss the femoral.

    Pt. knows the time and space.

    Family history: mother had CA, sister had a sore on her leg.

    Past surgical history: significant for multiple seizures to her ear drum.

    Paul is a 74 y.o. gentleman who is older than his years.

    IV Nafcillin will be started on the basis of quality of staff (sic) coverage and penetration of the CSF.

    She had felt reasonably well over the last week when she had the sudden onset of shortness of breath while driving her coronary artery.

    Arrangements were made to transfer the pain to another hospital where he was to have coronary angiography.

    Isn't this a funny business???????????? )






    martinalpn, CrazyGoonRN, sharpeimom, and 3 others like this.
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    Doctor was charting on a patient with abdominal pain. The patients name was Paulette. "Patient denies pregnancy, denies hysterectomy but states has never had a menses. Plan: Beta HCG and pelvic exam" I would have really liked to be in the room when that physician tried to do a pelvic. You see Paulette was a frequent flyer whose birth name was Paul. He actually looked like a very beautiful woman, but at this point had not had any sex change operations, only hormones.
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    These are really funny!

    In a docs H & P he wrote 'This is a 88yo BM' BM of course for black male.....well......he dictated his note & the finished product read 'This is a 88 year old bowel movement'. Talk about old pile of $hit......just kidding

    Last edit by misti_z on Oct 22, '01
  10. 5
    At change of shift, 5 RNs, 3 LPNs and the nurse manager huddled over a chart where the pediatrician had just ordered what appeared to be "TL". All that combined nursing knowledge could not decipher what TL could possibly stand for. Finally we admitted total ignorance and called the doctor. Aha!! His rushed handwriting had caused his "TC" for throat culture to look like TL!!!!!
    Moral of the story--beware of abbreviations!


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