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 DD, Geriatrics, Neuro.

I saw a physician write "Patient's PERRLA".

I sat down next to him and said, "Wow, that is amazing, I got to go look at that patient again."

He said (rather annoyed), "Why?"

Me: "Because that left eye has got to be the best damn prostetic I have ever seen!"

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we had a nurse on our unit chart "pedal pulses palpable bilaterally" on a bilateral amputee.

the doc amusingly inquired if it was the dorsalis pedis or posterior tibialis.

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Here's one I almost put into a computer order. Our gyn on-call admitted a patient and wanted to be present for the pelvic U/S... he said he wanted to watch in case he saw something the tech didn't. When I was entering the order, I wrote "please page Dr. when patient goes to U/S, he wants to watch" THANK GOD I always double check myself before hitting the enter order!

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Specializes in ortho/neuro/general surgery.

The other night on the surgical floor, I had one patient that was s/p self-inflicted abd. GSW and another one that was in a for a bowel obstruction which was resolving without surgical intervention (and 8 other patients:uhoh3: , but that's beside the point:o ).

Anyway, when I opened the computer charting on the bowel obstruction I saw that the last nurse had charted about an incision and JP drains on him. I almost jumped up and took another look at his belly, but instead I double-checked the 'procedure' section of his chart and saw that I was correct, he definitely had NOT had any surgery. She must have confused the GSW with the bowel obstruction when she charted. ;)

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Specializes in Psych, Extended Care, Med/Surg.

Had a doctor ask me about a monthly note that stated "Pt. continues to be on coking precautions" and wondered if they perferred Pepsi. (choking)

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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.

In surgery, the ENTs use a foley immediately after doing the adenoidectomy to apply pressure and stop bleeding. Once it is in place, they proceed to the tonsillectomy and remove it later. Works like a charm! Given my son's propensity towards horrendous nosebleeds, I'm tempted to take one home and keep handy for when he gets one ROFL!!!

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Specializes in PICU now, Peds and med-surg in the past.

Just the other day I was reviewing the H&P for a 23 year old patient of mine. Under Family History, it was written "Mother died at 46 of a head and neck cancer". The next sentence was "Pt lives at home with 60 year old mother who is alive and well". So, I wonder how long that AMAZING lady was dead before she came back?!:banghead:

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Specializes in Orhto, med/surg.

This was the norm for "Carol". She was an RN, if you can believe that. "This pt likes to think that he has all of the answers, but he obviously does not by the things that he says". This "Carol" would write 1-2 page notes about gossip she heard from the patient.

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Specializes in TCU,ICU,OHRR,PACU,5Solid Organ Transplan.
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)

Glad to see I'm not the only one!!!

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Specializes in Education, Acute, Med/Surg, Tele, etc.

I once accidentally wrote an order for ducolax suppository PO! LOL, oh pharmacy had a fun time with that!

When asked I simply said "well the patient has an inoperable case of verbal fecal syndrome...LOL (in other words...used vulgarity!). LOL!!!!!!

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Specializes in High Risk In Patient OB/GYN.

when I was a medical assistant in an urgent care clinic, I was trying to describe a Pt's cyst which had a thick, odorous d/c, but not knowing the proper term, I wrote "Pt c/o cyst c thick, ***** d/c" as in, it had pus coming out.

When that was pointed out to me, man I wish we could have used white out!

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Specializes in Neuro Surgery,telemetry.

i was working on a opthamology ward 6 years ago and read about the previous nurse's chart saying "admitted a 65yo male.....IVF of 0.9% NS inserted via left eye"

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