Charting Bloopers - page 9
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
- 3May 7, '02 by sandigapeachlpnI 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!
- 6May 17, '02 by NurseMonkeyI 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"
- 9May 18, '02 by ChristenLPNThe 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!
- 4Jun 3, '02 by DF-LPNThis 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