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:

Quote
"Patient vehemently denies any auditory, tactile, or old factory hallucinations."
Specializes in Hospice, LTC.

One of my goof ups that I caught was:

Pt found sitting up in electric chair, no s/sx of distress or anxiety noted.

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Specializes in Oncology.

I caught myself charting this the other day:

"No Lasix given for I>O due to inaccurate output record on previous ****."

It was suppose to say "shift."

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Specializes in Medical/Surgical.

Patient satting 95% on 50% "vinny" mask.

Patient with history of "cabbage" in '07.

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Specializes in Making the Pt laugh..

Heparin and TEDs s/c.

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In home health, I once charted "pt discharged home from hospital with assistance of "souse"...wearing "thigh high RED hose" (typos on computer charting)

It sounded like those two had quite a night ahead of them!

*wine

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I may or may not have written "Pt states hx of pancreatitits, thinks is having relapse" on an intake form, but I cannot confirm or deny any such occurrence.

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Specializes in Pedatrics, Child Protection.

Keeping a list of admitting diagnoses lately.....

Inflammatory BAVEL disease

Hyperbilirubin Anemia

...can't remember the rest...should have writtent them down!

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Specializes in Emergency.

Heres my favorite:

Med transcriptionist charting a transfer summary listed a med as :"Cigarette 180mg daily" (it was supposed to be "Cardizem 180mg daily").

Amy

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Specializes in Obstetrics and Gynaecology, Medical.

w/ o2 cannula attached to uro bag...

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Just the other night, in an H&P on a hip fx:

"Patient is allergic to Percocet, Tylenol #3, and Darvocet. All those medications caused goofy."

A- that's not an allergy, that's a side effect

B- if those meds "caused goofy"- what caused Mickey and Pluto?

"Fall: The differential diagnosis is mechanical vs. syncope. Since patient is not unconcious, syncope unlikely."

Sure, doc, cause no one could ever pass out and fall, then come to in the 8 hours between when he fell and when you dictated this?

To his credit, english wasn't this doc's first language.

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my fav is

"pt pleasantly confused"

and the time one of our male nurses charted that he examined mr smiths lady parts

I wonder if "pleasantly confused" is a legitimate description. I have also seen this on multiple LTC charts, i thought it was funny at first but then I began to wonder...

By the way everyone, keep the hilarity coming! I laughed so hard on some of these I think I might have strained something.

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Specializes in Rodeo Nursing (Neuro).
I wonder if "pleasantly confused" is a legitimate description. I have also seen this on multiple LTC charts, i thought it was funny at first but then I began to wonder...

By the way everyone, keep the hilarity coming! I laughed so hard on some of these I think I might have strained something.

Sorry to get serious--it's so unlike me--but you raise a fair question. I've used that expression, at times, but is it legit? Some patients are surely more "pleasantly" confused to the staff--cute and funny, as opposed to confused and agitated or confused and combative. But it does at least appear that some confused patients are in a happier alternate reality than others. But it's worth remembering that pleasantly confused can turn to fearful rather quickly. I'm thinking of a lady who thought her television was a window and was enjoying watching all of the horses running in the yard, but then was alarmed by a close-up of Audie Murphy and thought he was a peeping-tom.

Still, she was a happy little 90 y.o. girl again in a few minutes. I guess if you have to be confused, it's better to be happy.

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