Charting Bloopers

Nurses Humor

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Specializes in med/surg, cardiac/telemetry, hospice.

Have you seen any charting bloopers?

Found in the History and Physical section of a patient's chart who had experienced visual hallucinations while ill:

Quote
"Patient vehemently denies any auditory, tactile, or old factory hallucinations."
3 Votes

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)

2 Votes

Found in pt progress note from resident md 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 .

2 Votes

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.

2 Votes
Specializes in NICU, Infection Control.

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!

1 Votes

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...."

3 Votes

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."

3 Votes
Specializes in Med/Surg, ICU, Cardiac ICU.

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).]

2 Votes

From the physician progress notes on a patient with a glass eye:

"PERRLA"

4 Votes
Specializes in Emergency Room.

Recently I saw an order that read: "Nitropatch 0.2 qd IVP"

Still wondering how to liquify that patch!

3 Votes

I saw this one in a chart review the other night, "Pt. reports relief from rectal exam per MD"

3 Votes
Quote
Originally posted by AHarri66:

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!

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?

Hugs, Nofear4me

3 Votes
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