actual sentences found in pt hospital charts

[almostanurse]

1. She has no rigors or shaking chills, but her husband states she was very hot in bed last night.

2. patient has chest pain if she lies on her left side for over a year.

3. on the second day the knee was better, and on the third day it disappeared.

4. the patient is tearful and crying constantly. she also appears to be depressed.

5. discharge status: Alive but without my permission

6. Healthy appearing decrepit 69 year old male, mentally alert but forgetful.

7. the patient refused autopsy

8. The patient has no previous history history of suicides.

9. patient has left white blood cells at another hospital.

10. patient had waffles for breakfast and anorexia for lunch.

11. she is numb from her toes down.

12. occasional, constant, infrequent headachs.

13. rectal examination revealed a normal size thyroid.

14. she stated that she had been constipated for most of her life, until she got a divorce.

15. examination of genitals reveals that he is circus sized.

16. skin: somewhat pale but present.

17. the pelvic exam will be done later on the floor.

18. the patient has two teenage children, but no other abnormalities.

:chuckle

[nursedawn67, LPN]

funny! :roll

[nursedawn67, LPN]

funny! :roll

[Kimt]

:roll :roll :rotfl: This is tooo....funny. Haven't laughed like that in awhile. Will post this on the bathroom wall at work for all to get a look at. After all....laughter is the best medicine.

[Kimt]

:roll :roll :rotfl: This is tooo....funny. Haven't laughed like that in awhile. Will post this on the bathroom wall at work for all to get a look at. After all....laughter is the best medicine.

[VivaLasViejas, ASN, RN]

Here's one I found in a resident's chart recently after she'd been in the hospital for CHF exacerbation: "We will diurese the pt. and monitor her eyes and nose over the next day or two to make sure she doesn't become dehydrated......" etc., etc. Of course, it was supposed to be I's and O's, but I figured the transcriptionist was either not paying attention or was fresh out of class!! Even the non-nursing staff who saw this howled with laughter!! :chuckle

[tattooednursie, LVN]

Some of those sound like something I would have wrote . . . I better check my charts now that I think of it lol

[Allison S.]

Here's one we found at our pedi rehab, where we have recreational outings for the kids:

"Enjoys boweling" (i.e bowling)

[whipping girl in 07, RN]

Last night I was finishing up at the end of the shift and I wrote: "Pt asleep. Ice chips given. Tol well w/o nausea."

Thank God I looked back at it again and changed it. Imagine the lawsuit if he'd later come up with aspiration pneumonia.

Lawyer: "Look at the chart. She gave him ice chips when he was asleep!"

:roll

[almostanurse]

:chuckle lol konni, thats too funny:chuckle

[MollyMo]

"Patient is board and hungry. Otherwise pain-free." (I posted this a while back and I still don't get it.)

[MidwifeWannaB]

Funny, funny stuff.

I'm probably gonna be guilty of those same mistakes.