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Discussion

Charting blooper

  • Experts

received this note tonight from our utilization review/coder rn:

this is your laugh for the night - one of the intake staff wrote:

pt has bowel cell ca of the face (basal cell).

i took such a fit of laughter.

thanks

glad the staff didn't copy that one.

  • Quote

    • Featured Replies

    • Guides

    Uh.......OOPS!!! :rotfl:

    Gotta love it when the transcriber doesn't have all their med. terminology down yet....I read an H & P note once on a new ALF admission who'd been hospitalized for CHF which said: "We will diurese her aggressively, then watch her eyes and nose for a couple of days and check lights daily w/ probable discharge to ALF/ICF....etc.". :lol2: Of course, the non-medical staff couldn't figure out why anyone needed their "eyes and nose" or their "lights" monitored, but the administrator (a former EMT) and I were howling!

  • Quote

    i love this kind of errors!!! th_laughingsmiley.gif

  • Quote

    Some things I've read in ER notes:

    The patient was recently diagnosed with "ear and double bowel syndrome." (Irritable bowel syndrome)

    The wound was urinated with normal saline.

    These always crack me up. Made me feel a little better when I found out the ER physicians use voice recognition software for their notes.

  • Quote
    • Admin

    Some.... interesting procedures as entered by surgical scheduling:

    -peritoneal craniotomy (is that a new approach requiring extra long instruments, or does the patient suffer from cranio-rectal inversion?)

    -Cabbage or cabage instead of CABG (which comes up automatically in the system, and they have to delete and retype. Not to mention food isn't allowed in the OR.)

    -exploratory laparotomy for bowl resection (how'd that get in there?)

  • Quote

    One of my nurses was an excellent nurse, but a rotten speller. I was doing chart reviews and found on the dementia unit she had charted "cognitive deficate". Once I stopped laughing I asked her if it meant "s**t for brains"!!?!?!

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