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."

pt. refused autopsy

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Specializes in Day Surgery, Agency, Cath Lab, LTC/Psych.

My favorite blooper was for my pre-angiogram patient's H&P. It read, "Patient unable to walk 112 blocks without shortness of breath."

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Before I was a nursing student, I worked in the authorizationd department of a busy ortho clinic and had to review the dictations from the physicians in order to request procedures, etc. One note from one of my favorite docs stands out "the patient states she is extremely pleased with the results of her Rt knee arthroscopy. She has moderate to severe dementia". That was six years ago and I still laugh about it 

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I remember an order "Hamburger Stat!". Also I hate to admit it but when I was in Nursing school..I was also involved with baking bread at home.. In my note i had written "Pt well able to make kneads known." Lucky for me my Instructer had a sence of humor and was aware of my baking hobby.

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I heard of someone charting "pt. had CXR of the right knee..."

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Specializes in Community, OB, Nursery.

Just this weekend saw that one of my pts had had a c/s with BLT.

Want some fries with that, sweetie?

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Specializes in LTC / SNF / Geriatrics.

On the calendar at the nurse's station we make notations regarding upcoming appts and such for the residents. Today I found this one -

So and so from ******** Hearing Center will be in to make a mold of *****'s R ear. (I knew what it said, 'right ear' but it just got my funny bone - taking a mold of someone's rear :roll)

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Specializes in NICU.

I was spending a clinical day on a pedi medical floor and was reading through my patient's chart and came across his diagnosis: "short guy syndrome" Me and the other student were stumped as to what this may be so we did a little investigation and it was supposed to be short gut syndrome. We had a good laugh about that one.

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Specializes in Community, OB, Nursery.
I was spending a clinical day on a pedi medical floor and was reading through my patient's chart and came across his diagnosis: "short guy syndrome" Me and the other student were stumped as to what this may be so we did a little investigation and it was supposed to be short gut syndrome. We had a good laugh about that one.

A bit OT, but I have heard "short guy syndrome" or "Chihuahua syndrome" used to describe docs who are short and try to compensate for it by being really 'yappy.'

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NVsGirl said:
Found in the history and physical section:

Patient is on IV D5 1/2NS with Kay Ciel 20 meq/L.

We got a kick outta that one! Oops.

I agree. What a giggle. But I bet the billing department didn't share that. I would hate to be the one that had to defend that oops in court.

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I saw this one in a chart review the other night, "Pt. reports relief from rectal exam per MD"

Yuck! A mental image I REALLY don't want stuck in my head.

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On an ER flow sheet, "16 Fr foley inserted to pt's L nare." ????????

This one I could actually see happening if the doctor was using the balloon to apply pressure to a bleeder. God, I hope that was what was going on. I would hate to hear that there was like 200ml of clear yellow urine returned.

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