Charting Bloopers - pg.7 | allnurses

Charting Bloopers - page 7

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... Read More

  1. Visit  LilgirlRN profile page
    I took care of a bedbound patient once who was just a litttle bit eccentric. She was perfectly well groomed, no bedsores, had round the clock sitters but wouldn't let anyone touch her feet. The H&P ended with this line..."And she has the longest toenails I've ever seen in my whole life"
  2. Visit  l-andre profile page
    Absolutely hilarious!
    I'm laughing like crazy in here!
    carolmaccas66 likes this.
  3. Visit  AIS52 profile page
    We recently had one of the newer residents diagnose a patient with "Left Middle Lobe Pneumonia!"

    I guess anatomy wasn't her strong point!
  4. Visit  sandigapeachlpn profile page
    I was doing my power charting the other night. i was in my robot mode going down the list on my alert charting board. i picked up the name placed it on the 24 hour report and documented 'no problems, sleeping" ( i work noc), then i realized that she had expired on eve shift, i was involved in shipping her out. think i am alittle stressed? i am on vacation this week thank god!
  5. Visit  NurseMonkey profile page
    I 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"
  6. Visit  boobaby42 profile page
    I have a bad habit of spelling pus or puss, oh heck, which ever, wrong. Everybody gets quite a jolt reading my notes decribing an infection. Pus filled or puss filled. You decide.
  7. Visit  ChristenLPN profile page
    The funniest thing I ever read was about an annual exam on an elderly woman who had been accompanied by her daughter:

    "When I advised the patient that I would be finishing the examination with a rectal exam, I learned that the last fellow to attempt a rectal exam on this patient was hit with a purse and kicked in the groin. Patients daughter was of the opinion that a rectal exam would not be in my best interest and I am in basic agreement with her."

    What a cool one he must have been!
  8. Visit  wheelie profile page
    Several years ago when I worked in a CVICU, I recieved a patient from the OR after a CABG. His operative premit stated he had a "coronary artery bypass with cabbage perfusion".
    carolmaccas66 likes this.
  9. Visit  zapperbapper profile page
    Recieved a pt late in the afternoon after she coded on the floor. The nurses am narative stated "pt found apnic and unresponsive. Will monitor"
  10. Visit  donmurray profile page
    "coded on the floor" What, no bed? (just kidding!)
    steph, I'd go with one "s" in pus, you only need two if you put a "y" on the end, and that can be misinterpreted!
    SomedaySoonNY and carolmaccas66 like this.
  11. Visit  nrsfear profile page
    this one is the fault of the dictation transcriptionist:
    on the H&P' "the pt is a stay at home milk of magnesia"
  12. Visit  DF-LPN profile page
    This was in the H&P:
    patient states only drank 2 or 3 beers until he met his wife.

    was working 3rd, got report from the nurse on a res how ate dinner then aspirated and was having resp distress. went and assessed res came back and read the previous charting which stated:

    res ate 25% of meal, started coughing then vomited lg amount of foot.
    next entry went like this.

    res lungs moist through out with audible wheezing noted, notifed dr of res having vomited lg fool and aspiration.

    seems to me that throwing a foot and/or a fool would cause me to aspirate LOL

  13. Visit  DF-LPN profile page
    had a res come from the va hosp so him and his wife could be together. his wife was a real PITA and never liked to get outta bed and gave everyone a hard time.

    the husbands dc summery stated:

    this res wishes to be dc'ed to ltc to be with wife, as i have known this couple for a long time i do not recommend this move.

    guess he's had several run ins with this lady LOL

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