Charting Bloopers

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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."
Specializes in 5 yrs OR, ASU Pre-Op 2 yr. ER.

Suck balls QID. I wouldn't get anything done from laughing too hard over reading that order LOL!!!!!!!!!!!!!!!!!!!!!!

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I transferred a pt with pneumonia to the hospital one day. Instead of charting that she went to NVCH-the hospital in my town, I charted that she was sent to NVHS-the High school. I caught the mistake the next day.

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I hadn't changed my profile yet, I was officially an LPN a little over a week ago!

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

Maybe when the exam was over? I would be!

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Specializes in HIV/AIDS, Dementia, Psych.

When I come back from work after a few days off, I read the charts of a few pts. who have been on report to see what's going on. On Saturday I saw the nurse had written on report that Ms. 'A' had an incident...ok. I went into the chart to see what had happened and lo and behold, the note read something like this...

"Resident had incident at 10am. No c/o pain or discomfort. Oncoming shift made aware. Incident report #439 filled out."

OMG!! First of all...she had an incident?! Well what in the HECK happened to her? :rotfl: Secondly...incident reports are IN HOUSE tools! you're never to write that you filled one out in a note...sheesh! :chuckle

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Specializes in 5 yrs OR, ASU Pre-Op 2 yr. ER.

Saw "pt. could not recall losing consciousness" again in nurses' notes.

Valsalva maneuver charted as "Salsa maneuver". Now i wonder, was it picante or extra chunky? Or are we talking about a dance here....

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Specializes in LTC, CPR instructor, First aid instructor..

A new intern to our CCU once charted attempts to cardiovert a patient in the following manner:

Attempted to convert the patient with 200 jews, unsuccessful. Second attempt to convert the patient with 300 jews unsuccessful. Patient finally converted on the third attempt with 300 jews.

The mental picture of three hundred rabbis surrounding a patient's bed yelling, "Convert, convert!" was too much. We nicknamed him "Call a Code or Call a Rabbi" from that day forward.

Hee,hee,hee,hee,ha,ha,ha,ha! This one is soooo good! 

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OHhhhhhh Frances,

What are we to do with you ? 

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:rotfl: iam cna work inteaching hospital . learning how to chart wrote pts member in tact

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Specializes in CCU (Coronary Care); Clinical Research.
panda_181 said:
One of my co-workers said she saw a chart that said "Pt had large bowel movement ambulating around floor!"

Amanda ?

I have seen this happen--more than once. It is not pretty. 

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Specializes in LTC, CPR instructor, First aid instructor..
zambezi said:
I have seen this happen--more than once. It is not pretty. 

The word describing the size of the bowel movement is too ambiguous.. It should be described by a comparison to an object. ex: While ambulating, pt had a bowel movement the size of a hockey puck, Jane Doe RN

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Lynn Casey RN said:
A collegue wrote..."pt states "slept well until nurse came in to get on patient"(instead of check on pt!)LOL!

Sounds like a bad adult film! 

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