Charting Bloopers

Updated:   Published

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 ub-Acute/LTC, Home Health, L&D, Peds.

When I was a brand new nurse I also used this word in charting to describe wound drainage. A very nice nurse brought this to my attention and helped me change it. I was so embarrassed!! I guess a lot of new nurse's make this mistake.

Up Vote Up Vote ×
Specializes in Oncology, General Medicine, Cardiology.

Nurse wrote in the patient's chart: "Fed patient. Patient spat on me. I spat back."

Ha ha...some people are really digging their own grave.

This nurse got fired after trying to sell raffle tickets to patients for a wheel chair raffle that did not exist.

Up Vote Up Vote ×
Specializes in NICU.
katfishLPN said:
When I was a brand new nurse I also used this word in charting to describe wound drainage. A very nice nurse brought this to my attention and helped me change it. I was so embarrassed!! I guess a lot of new nurse's make this mistake.

I guess I'm lucky...I used that word in a sixth-grade science assignment and got detention for it. Will NEVER use it again.

Not to mention my visceral hatred of the word as it pertains to the female anatomy. Won't even use it for a feline...YUCK. I'd rather hear the C word, and that's no lie...

Up Vote Up Vote ×
I work in a nursing home. The other night one of my aids called me over the call and said, "Mr. ____ has a bad rash on his prenatal area and needs some cream." I was laughing so hard and she came out of the room and said, "Are you laughing at me?" I could only shake my head 'yes.' I finally explained to her what prenatal was and told her she meant perineum.

Gosh! No Hippa laws in SC? Her butt would have been reamed in our facility for blasting that over the intercom for violating his privacy. I would have a talk with her about this so it doesn't happen again. How embarrassing for him, if he has the capacity, but even if he doesn't he still has the right to his privacy. Just my two cents.

Up Vote Up Vote ×

I saw an ER note that read, "Pt co of liquid diarrhea running from house x 3 days."

Yuck, glad I don't have to visit that house! lol

1
Up Vote Up Vote ×

I got pulled off my unit to work as the Unit Clerk on another floor (at RN wages, how's THAT for cost-effective planning!?!), and got this one to transcribe: "Pt may walk on floor". Must have brought her down to earth!

Savvy

Up Vote Up Vote ×
Specializes in Emergency/Trauma.

I'm a student, and in one of my discharge notes on a pediatric patient I charted: "Mother placed in infant car seat" instead of "Mother placed infant in car seat". My instructor tracked me down with the chart and told me she would like to see that!

1
Up Vote Up Vote ×
Specializes in ob-gyne and OR nurse.

the patient was comatose, post partum for 6hrs. and a medicine doc have an order like this. "NPO except oral meds" How can a comatose pt. swallow an oral meds. 

Up Vote Up Vote ×

These posts are great!!

Here's one of my favorites written by ID in the progress notes of a long-term vent patient we had in ICU:

Day 445.

Here longer than the hostages in Tehran, with much less hope.

and this one, written by a very tired noc shift RRT....pt remains being ventilated.

1
Up Vote Up Vote ×
WHAT??? Never heard of such a thing. :chuckle I guess where ever this is they don't have nose bleed kits...ya know the thing that looks like a tampon that is inserted into a nare....has a string hanging out....a foley cath in the nare? I have to ask around about that one...hey, whatever works! :chuckle

I'v seen it in A&E pt had the worst nosebleed iv ever seen they thought it may be a GI bleed, ENT doc tried packing it normally this didn't work, so a fellow student stood hold a foley coming out a a patients nose.

Up Vote Up Vote ×

Our teacher always tells us that in writing nurse's notes, it should include the whereabouts and activities of the patient. Here's something my teacher told us. It's not exactly the same but it goes like this:

[...assisted Patient X in standing up from bed, walked three steps toward the door. Then, turned the knob and opened the door. Walked 10 steps...]

Hahaha...too specific! 

Up Vote Up Vote ×
Specializes in NICU.

When charting a few weeks ago, instead of typing "blowby", I typed "blow boy" 

Up Vote Up Vote ×
+ Join the Discussion