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."
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.

Wonder why they didn't use a suction cath?

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TriciaRN said:
Hmm, guess that doc needs a new assessment class, ROFL!

I remember an old, scruffy oncologist from years ago. He actually would walk up to the patient, move his stethoscope over the chest.... even though the ear pieces were clasped around his neck instead of in his ears  Always wondered if the patient's caught on?

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Wonder why they didn't use a suction cath?

I think the idea is to inflate the balloon and apply pressure w/ it. That's the way I've seen it done. I don't understand what you would do w/ suction cath except to remove the blood, which wouldn't stop the bleeding. Is there something else you could do w/ it to control the epistaxis?

Savvy

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Specializes in Utilization Management.
what's wrong with this one? just curious... i have charted "pt sleeping quietly" before...

You can describe "sleeping," you just can't say it:

"Pt resting with eyes closed, skin pink, warm, dry, and respirations even and unlabored."

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Specializes in Pediatrics.

huh... didn't know that... why?

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Specializes in NICU.
huh... didn't know that... why?

I imagine it's because you don't actually know that the pt is sleeping - might just be lying quietly w/ eyes closed. Not to say that it's not used all the time.

I've seen a number of folks use their steths with the earpieces on the mastoid process.

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Specializes in Utilization Management.

Pt could also be unconscious, I suppose....

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

This isn't something that was charted but something that happened to me. I had an unconscious patient in a SNF. I did an assessment I don't remember the particulars but I called the doc and got an order to send her to the ER. I called the ambulance and over the phone the dispatch guy asks me if she was conscious and I said "No". So when the EMT's get there I take them into the room and one of them says "I thought you said she wasn't conscious, she's still breathing" I just looked at him dumbfounded thinking ya if she wasn't breathing then she would be dead duh!!!!!!!!!!! :trout:

But didn't say it out loud.

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Specializes in Med/Surg/Tele.

that PERRLA one is hilarrious. Ok a dr calls me into the room (student nurse wotking as a tech), and says, yes, this pt bed is not working, we need to have a new bed ordered. I look and the plug is hanging 1/2 way out of the outlet. DUH! You can bet we were all giggling about that at the nurses station

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Specializes in ER, Hospice, CCU, PCU.

Written in the transfer notes on a patient received from a nursing home. "Pt has had no temperture for 3 days and keeps falling off the floor"

1
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Specializes in Surgical wards, Elderly Care.

I saw a triage sheet that stated

"child has suffered dog bite by rabbit"

Wow i wonder what animal would give a rabbit bite..................

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Specializes in OR, PACU, GI, med-surg, OB, school nursing.

Pt in ED for a dog bite; MD wrote

"Patient was bitten by his own doctor"

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