Charting Bloopers - page 74

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. 3
    Progress note read: Resident continues to C/O severe lower back pain after fall this AM. PCP notified and orders given for x-ray to her scrotum.
    GM2RN, sharpeimom, and Christy1019 like this.

    Get the hottest topics every week!

    Subscribe to our free Nursing Insights newsletter.

  2. 1
    Oh I have a great one....we had a pt. on abx for a staph infection in his penis. We still used paper charting and at the end of a VERY long day, while trying to quickly chart before my shift ended, I charted "Pt. continues on abx for staff to penis" of course you can only put 1 line through the mistake so everyone got a good laugh. LOL
    SomedaySoonNY likes this.
  3. 0
    Have seen one ER note say "wound is red and *****" (No wonder they invented the word purulent). Had another where doc wrote time, including the seconds, on his note after being told numerous times to date and time his orders. Last one is my favorite, doc wrote progress note on patient that said "Said hi" "She feels better today". !!
  4. 3
    Patient walks in to GYN clinic and refuses any contraceptive methods stating "I do not have sexual intercourse, I have outercourse".
  5. 2
    I've been collecting these for 10 years.
    Actual writings from Charts in a Hospital: .

    1. The patient refused autopsy.

    2. The patient has no previous history of suicides.

    3. Patient has left white blood cells at another hospital.

    4. She has no rigors or shaking chills, but her husband states she was very
    hot in bed last night.

    5. Patient has chest pain if she lies on her left side for over a year.

    6. On the second day the knee was better, and on the third day it disappeared.

    7. The patient is tearful and crying constantly. She also appears to be depressed.

    8. The patient has been depressed since she began seeing me in 1993.

    9. Discharge status: Alive but without my permission

    10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.

    11. Patient had waffles for breakfast and anorexia for lunch.

    12. She is numb from her toes down.

    13. While in ER, she was examined, x-rated and sent home.

    14. The skin was moist and dry.

    15. Occasional, constant infrequent headaches.

    16. Patient was alert and unresponsive.

    17. Rectal examination revealed a normal size thyroid.

    18. She stated that she had been constipated for most of her life, until she
    got a divorce.

    19. I saw your patient today, who is still under our car for physical therapy.

    20. Both breasts are equal and reactive to light and accommodation.

    21. Examination of genitalia reveals that he is circus sized.

    22. The lab test indicated abnormal lover function.

    23. Skin: somewhat pale but present.

    24. The pelvic exam will be done later on the floor.

    25. Patient has two teenage children, but no other abnormalities.

    hope you enjoy them as much as I did
    pseudomonas and sharpeimom like this.

Nursing Jobs in every specialty and state. Visit today and Create Job Alerts, Manage Your Resume, and Apply for Jobs.

A Big Thank You To Our Sponsors