We all got a good laugh at work after reading a consultation from our ID doctor. She wrote...pt has large amount of ***** drainage... we decided that purulent might look better. (Keep in mind it was a slow day)
Found in pt progress note from resident md re t mental status(Pt had been confused for several days):"continues to be confused. Oriented to person, place, and time." I could not help but wonder if the md has seen the pt @ all. Did get a laugh out of it .
As we were reviewing a chart on the Alzheimer's unit - this notation stood out:
"resident very agitated - yelling profound statements" Profane yes - profound no ..I doubt he was yelling "To be or not to be....that is the question...."
I recently saw a "add 20 mEq Kay Ciel to existing IVF" order also. Maybe these docs were trained at the same place.
We also had an order recently that to us really brought into question the integrity of the writer. The order was for "1 baked potato p.o. bid". First, where else would a baked potato go and secondly, dietary requests do not need to be written by a doc in the orders sheet!
[This message has been edited by ClariceS (edited December 27, 2000).]
[QUOTE]Originally posted by AHarri66:
[B]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."
At our hospital they allow aides to write in nurses notes!! This is a true note, "patient don't move all day. Just lays there." When second shift arrived a code was called on the mentioned patient. The doctor stopped the code and yelled, "this pt expired hours ago" As nurses on our unit we are trying to stop the aides from note writing. Does anyone know the law from Pennsylania?