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."
Specializes in Utilization Management.
jollygreenRN said:
How about this one?

"Patient has been living with her mother for the last 15 years, who is deceased.":eek:

Hmmm...must be one of William Faulkner's relatives. 

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Specializes in PeriOp, ICU, PICU, NICU.
jollygreenRN said:
How about this one?

"Patient has been living with her mother for the last 15 years, who is deceased.":eek:

Yikes! I bet she has been mummified or her ashes are in a box 

LOL

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Specializes in ortho/neuro/general surgery.

A co-worker of mine recently accidentally charted a male patient as having a period, and quite a long time ago charted that an 84 year old lady was pregnant.

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Specializes in ortho/neuro/general surgery.
During clinicals, writing our notes was a bit nerve racking. we had to write it out and then show our clinical instructor, she would make changes/suggestions and THEN we would put it in the chart...Anywho, I got a little bit distracted while transcribing the note to the chart. I'll never forget when i came in the next day, and the Instructor pointed out what I had wrote. "....Pt breathing." Uhm, here's your sign!

Well, sounds like you understood the ABC's- airway, breathing, circulation! :chuckle :chuckle

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Specializes in ortho/neuro/general surgery.
I think they should rename go-lytely to go ever so heavily !

Or call it Ever-so-easily-poured-down-the-sink-by-the-noncompliant-abdominal-pain-patient-and-replaced-with-water (enemas til clear, anyone?)

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Specializes in ICU/CCU, Home Health/Hospice, Cath Lab,.

I caught this one in a dictated H/P

Pt is married, other medical problems include (with a list)

Still causes me to chuckle to this day.

Pat

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Specializes in NICU.

seen today:

pt ambulatory c/o existence....

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My personal favorite was written by a very prudish LPN that read "Oral peri-care given" I asked her if the patient enjoyed it and then suggested using a comma next time she documented hygiene.

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In Med/Surg Clinical someone had written (the physician, I assume) in a chart: Lomotil, diarrhea PO 25 mg....Is 25 mg of diarrhea a standard medication to give? :chuckle :uhoh21:

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I have to pay attention when I chart. If someone is talking, even though i am not consciously hearing, my mind listens to the conversation.

I got called the following day to clarify my charting the evening before because I had charted,

"Patient voiding orange juice."

:chuckle

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Specializes in ICU, telemetry, LTAC.

This week we had a transcribed h & p that said the male patient had a history of a Fundal Plication. Well. I wasn't gonna go looking for his fundus! (Fundoplication was his surgery for GERD)

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From the physician's notes about a first-time pregant, newly admitted OB patient: "Patient is a 26-year old primate".:rotfl:

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