Charting Bloopers

We recently had one of the newer residents diagnose a patient with "Left Middle Lobe Pneumonia!"

I guess anatomy wasn't her strong point!

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!

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"

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.

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!

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".

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"

"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!

this one is the fault of the dictation transcriptionist:
on the H&P' "the pt is a stay at home milk of magnesia"

This was in the H&P:
EOTH
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

Dee