Charting Bloopers

  1. 8
    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
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  4. 6
    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)
  5. 2
    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 .
    CrazyGoonRN and carolmaccas66 like this.
  6. 5
    Found in the history and physical section:
    Patient is on IV D5 1/2NS with Kay Ciel 20 meq/L.

    We got a kick outta that one! Oops.

    MaleICURN, RNowakowski, MARYRN2009, and 2 others like this.
  7. 1
    A Med Student recently ordered "D 10 ISO Pee" on a pt's chart. Even the Boss (totally preoccupied w/Mock Survey that day) Laughed!
    carolmaccas66 likes this.
  8. 39
    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...."
    Melmalaika, debsgreys, VictoriaGayle, and 36 others like this.
  9. 8
    Progress note, "The patient was BEAN BAGGED on 100% oxygen."
    From the ER, "A full examination will be completed with the patient ON THE FLOOR."
    blaundee, SuzieeQ, CrazyGoonRN, and 5 others like this.
  10. 9
    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).]
    debsgreys, SuzieeQ, CrazyGoonRN, and 6 others like this.
  11. 10
    From the physician progress notes on a patient with a glass eye:
    "PERRLA"
    Nina_k13, Lev <3, SierraMoodyRN, and 7 others like this.
  12. 15
    Recently I saw an order that read: "Nitropatch 0.2 qd IVP"

    Still wondering how to liquify that patch!


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