Charting Bloopers - page 74

by AHarri66 | 462,652 Views | 733 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

  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.
  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". !!
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    Patient walks in to GYN clinic and refuses any contraceptive methods stating "I do not have sexual intercourse, I have outercourse".
    vintagemother and Christy1019 like this.

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