Charting Bloopers

[AHarri66]

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."

[Adam D. RN2005]

Seen in my pts chart this evening: Please Toilet Mouth. Thank you.

Had the unit in stitches. What do we do, put toilet water in the mouth. I mean really. And this same md for another pt wrote, Change Prevacid to 30 mg IV. Well, he should have looked at his own orders because the Prevacid was 30 mg IV since the pt was admitted.

And another nurse noted that the MD wrote, if pt dies, don't call me or any resident. Huh?

[NrsBetty247]

Noted by a new RN in her assessment of a 5 month old with a prominent hemangioma.

"Pt with large round blue face per baseline"

First I stared, then I giggled, then I showed it to all the other "old" nurses. We got quite a kick out of it.

[SFCardiacRN]

As an RN student I had a patient with positive pedal pulses on every shift during his 2 week stay. However, he was a double amputee.

[Adam D. RN2005]

SFCardiacRN said:

As an RN student I had a patient with positive pedal pulses on every shift during his 2 week stay. However, he was a double amputee.

Well, you've heard of phantom pain, well, this is phantom pedal pulses.

[CardiacJennLPN]

I was reading the progress notes on a pt. who had just arrived on our floor. He was admitted with shortness of breath and a high temp. Someone working in the ER had charted "Hot-headed SOB with fever". We all got a kick out of it!

[magellin1]

One tired overnight RN at our facility charted that a child had recently returned from orthopedic surgery, pt had "MANSTRINGS" lenghtened.

[grace90, LPN, LVN]

From the physician progress notes on a patient with a glass eye:

"PERRLA"

We read that once in the neurosurgery progress notes of a patient that was sp lumbar surgery and had one glass eye. :chuckle Makes ya wonder!

[grace90, LPN, LVN]

CardiacJennLPN said:

I was reading the progress notes on a pt. who had just arrived on our floor. He was admitted with shortness of breath and a high temp. Someone working in the ER had charted "Hot-headed SOB with fever". We all got a kick out of it!

Were they talking about the patient or the doctor?

[tlhubbard]

Not a charting blooper--verbal.

0300 in ER (by squad no less) comes a minor with parent. Minor has not had BM in 1 week (it's emergent NOW??)

Order for milk/molasses enema was given.

Parent approaches me at the nurses station out of hearing for the minor and says, "She doesn't like milk"

I thought give me 5 minutes she's really not going to like it.

That girl must have taste buds a lot further back than most of us!! hee, hee, hee

[LearninRn]

Not a blooper, just read as a blooper. I work in a group home for MR patients. One patient (who is blind) went to her opthalmologist for routine visit. The progress note he sent back with patient said "Patient seen for f/u, no change in status, will see in 2 years). One of our nurse aids called this patient's mother and told her "Great news! The doctor said she will be able to see in 2 years"

Now. . . that's a darn good Doc!

[rainfallrx]

I recently saw on a patients H&P:

pt. was found at home by husband.....unable to move extremities.....HER SALIVA WAS DROOLING. What the heck is that. Everything else sounded so professional. I just busted out laughing. The other nurse on the floor just looked at me and shook her head. Hey it was a long night.

[FranEMTnurse, CNA, LPN, EMT-I]

1. The patient refused autopsy.

2. The patient has no previous history of suicides.

3. Patient has left white blood cells at another hospital.

4. Patient's medical history has been remarkably insignificant with

only a 40 pound weight gain in the past three days.

5. She has no rigors or shaking chills, but her husband states she was

very hot in bed last night.

6. Patient has chest pain if she lies on her left side for over a year.

7. On the second day the knee was better and on the third day it

disappeared.

8. The patient is tearful and crying constantly. She also appears to

be depressed.

9.The patient has been depressed since she began seeing me in 1993.

10. Discharge status: Alive, but without my permission.

11. Healthy appearing decrepit 69-year old male, mentally alert, but

forgetful.

12. Patient had waffles for breakfast and anorexia for lunch.

13. She is numb from her toes down.

14. While in ER, she was examined, x-rated and sent home.

15. The skin was moist and dry.

16. Occasional, constant infrequent headaches.

17. Patient was alert and unresponsive.

18. Rectal examination revealed a normal size thyroid.

19. She stated that she had been constipated for most of her life

until she got a divorce.

20. I saw your patient today, who is still under our car for

physical therapy.

21. Both breasts are equal and reactive to light and accommodation.

22. Examination of genitalia reveals that he is circus sized.

23. The lab test indicated abnormal lover function.

24. Skin: somewhat pale. but present.

25. The pelvic exam will be done later on the floor.

26. Large brown stool ambulating in the hall.

27. Patient has two teenage children, but no other abnormalities

28. When she fainted, her eyes rolled around the room

29. The patient was in his usual state of good health until his

airplane ran out of gas and crashed.

30. Between you and me, we ought to be able to get this lady pregnant.

31. She slipped on the ice and apparently her legs went in separate

directions in early December.

32. Patient was seen in consultation by Dr. Smith, who felt we should

sit on the abdomen and I agree.

33. The patient was to have a bowel resection. However, he took a job

as a stock broker instead.

34. By the time he was admitted, his rapid heart had stopped, and he

was feeling better.