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:

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

Yes I've read that on charts too when I was a student nurse not very long ago at all. The woman had Alzheimer's, the man had organic brain syndrome, both hard of hearing and the third patient was stable yet couldn't talk and was obviously disoriented and only opened his eyes to verbal stimulation. Yet all three were pleasantly confused. What does that mean anyway? Crazy!!!:)

my fav is

"pt pleasantly confused"

and the time one of our male nurses charted that he examined mr smiths lady parts

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Two good ones-

On the floor census, "S/P CABBAGE"

or

on the preop checklist in the belongings section "family took toilet trees home"

2
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Specializes in Gen Med,LTC.
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)

well how do you spell pu$$y anyway???

LOL

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One of my classmates computered charted that the patient's member was intact. One problem, the patient was a female!

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Specializes in NICU.

A classmate in nursing school actually charted, "The patient pooped in his pants."

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Specializes in Medical.

The "pleasantly confused" thing I understand, if you compare it with the many unpleasantly confused patients we get. I had one guy I was doing neuro obs on who, in response to "can you tell me where you are?" said "If you don't get out of my back paddock I'm going to shoot the lot of ya's!" Then there was the unpleasantly confused post-op woman who was scratching and hitting when we tried to prevent her removing her IV - in response to "It's alright, we're nurses" she replied "Nurses? Green b-tches from hell!" With that she kicked the poor RN next to me in the groin so hard he had to go to cas.

On a lighter note, a friend of mine recieved a patient with ataxia. I'm guessing fatigue is the reason the admitting doc put his admission diagnosis as "walklessness FI"

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

May the fleas of 1000 camels infest the crotch of the the person who messes up your day...and may thier arms be too short to scratch...:rotfl: :rotfl: :rotfl: I love it!!!!

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My sister charted once, that the patients central line was patent to dependent drainage with clear yellow urine........:imbar

I learned Purulent the hard way too......:imbar

I did Careplans and had heel protectors to be in place at all times while in bed, for a lower bil amputee. State surveyors found that one, but got a laugh out of it.

I also charted that resident had their toenails clipped, and was a lower bil amputee.

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From my first semester of nursing school (Fall 2003), while researching my patient for clinicals, the doctor's handwritting that I was trying to decypher was so terrible that entire sentences looked different from what it really ment. Example, this doctor wrote "the patient is a little stronger", but stronger looked a lot more like the word shrimp. Well, the patient was a bit on the tiny side.

Adam

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A classmate in nursing school actually charted, "The patient pooped in his pants."

That's OK, you're in school. Now, the resident (second year!) who charted on the H&P that the newly admitted lol with diarrhea/dehydration had "c/o pooping herself the last few days", ummm... Are ya too rushed to write fecal incontinence, don't know how to spell it, or is your med school diploma written in crayon?!?

And I'll second the understanding of 'pleasantly confused'. I'd much rather have a confused one who is happy in their mindset giggling at everything I ask or tell them, than the ones who yell, swing at you, argue when you attempt to reorient, etc.

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I found one on the orthopaedic ward.

"Patient felt dizzy after standing on bed during bedmaking" I could just picture the nurse feeling dizzy looking up at him :rotfl:

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Order for a grouchy old lady in the nursing home who constantly complains about the food, the noise, the sunshine, etc: " Prepare food to pt's satisfaction"

Hey, doc, you coming to cook?

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