Best MD note

[beckster_01]

There may or may not be a thread like this but I couldn't resist sharing. This weekend I was digging through my patient's chart trying to learn more about his history when I came across a note by the attending cardiologist. It said, and I quote: "Patient is stable, no complaints. Was screaming 'Kibbles and Bits!' repeatedly upon my arrival. Of note, patient does not have a dog." I couldn't help but laugh. Anybody else come across some interesting notes in their charts?

[dirtyhippiegirl, BSN, RN]

Came across a nurse communication order that read: "Please provide pants for the patient. Thank you very much!"

Initial diagnosis of "flaming pumpkin vs. pedestrian" (which was an accurate portrayal of how the patient got burnt.)

[rehabwoundnurse]

Had one doctor who would chart things like "family tree doesn't branch far" and "****, we've tried everything and still don't know what's going on!" And same doc also charted "this patient to dumb to talk to, he understands nothing". A little harsh doc!

[skylark, BSN, RN]

I recall a doctor who used to write OBTAA in the notes of regular attenders who never had anything wrong and just wanted to tell him their entire life story over and over.

When asked, he told me that the 'official' meaning is "observe before taking any action".

And the unofficial?

"One bl***y thing after another!"

[TopsDrop, RN]

My favorite one just happened recently actually. It started off something along the lines of "this patient's has to many problems to even begin to explain in this H&P, Her history is very long and complex so please refer to previous notes and good luck"

The entire H&P was hilarious I was cracking up the entire time.

Best part was the plan.

"check for signs of osteomyelitis and then I have no idea from there at this time"

[beachmom]

This was a night shift nurse's note in a LTC facility. "No pulse, no BP. Will keep comfortable."

She left the next morning, saying nothing about it to the day shift. Day shift CNA, of course, found pt. dead. The nurse was let go. I always wondered what the official time of death was, and if the facility told the family about this.

[BostonFNP, APRN]

This was a night shift nurse's note in a LTC facility. "No pulse, no BP. Will keep comfortable."

She left the next morning, saying nothing about it to the day shift. Day shift CNA, of course, found pt. dead. The nurse was let go. I always wondered what the official time of death was, and if the facility told the family about this.

Was this pt CMO and the nurse was documenting to keep comfortable and not take pulse and BP anymore?

[BostonFNP, APRN]

My collaborating doc is very (pleasantly) unpolished, man of few words, and direct (and strangely enough patients love him). I was doing a 3 month follow up and came across one of his comments in the problem list under obesity: "she is still fat, doubt it will change, keep trying.".

[marydc]

My favorite was a note made by the psychiatrist after a patient had intentionally kicked me in the stomach. "Patient is well aware of right from wrong. In my opinion needs a therapeutic trip to jail."

[chare]

One of our pediatricians .charted child bitten by dog 10 days ago mom states dog is fine, nothing was ever charted about how the child was doing.

Hey some people have their priorities in that order... LOL... Aloha~

I realize that this is an old post, however this is actually important information. If the dog is fine 10 days after after the incident then it is not rabid. If the child has not started the rabies series then he or she will not have to do so.

Having undergone the rabies series several years ago, I can assure you that it is not fun; especially the human rabies immune globulin (HRIG).

[al7139, ASN, RN]

Order for one cigarette q day. He had a very heavy accent and was misinterpreted by the scribe

[serenidad2004]

Dictated by my favorite nephrologist in a progress note about a very complicated patient "it appears we are still up sh*t creek without a paddle" I had to read it 3x before I believed it.

[dariah]

I once came across this gem in the chart of a PCOS patient...

"Pt has hair like a man"