Charting Bloopers

[AHarri66]

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."

[bassandtea]

From one of my friends "Diagnosis: Sick" That's all that was written... Sick with what?

[aKyRN81]

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.

The term 'pleasantly confused' has been in use for ages and means exactly what you describe. The patient is not distressed, fearful, or hostile in regards to their confused status. It's not a diagnosis, just a description of current state of mind.

[faline1973]

Before he dictated, one of our cardiologists stated "That woman is NUTS. Absolutely crazy. She hops from hospital to hospital. We've done every possible test on her and there is nothing wrong. She's taking 200 mg of aldactone a day. It is scientifically impossible for her to be hypokalemic unless she's taking a diuretic and she swears she isn't. She is CRAZY and I'm putting that in my dictation!

Sure enough... he wrote "Unsure if patient has mental problems with an anatomical reason such as deteriorating white matter or is intentionally trying to confound her physicians."

:chuckle

[mangosteen]

What about new factory hullicinations? ha ha.

[texas2007, BSN, RN]

One of our admitting diagnoses is "Full term neonate with major problems". OK then...Have seen it on multiple charts...

[beachmom]

My friend's gramdma had a reaction to Demerol. The doctor wrote in large letters:

DEMERAL = CRAZY

Several times I have seen doctors write "foley to gravity"

What other kind is there? Put in a foley to suction?

[Elvish, BSN, DNP, RN, NP]

Several times I have seen doctors write "foley to gravity"What other kind is there? Put in a foley to suction?

For bladder retraining purposes, you can put a foley in to intermittent drainage.

[prmenrs, RN]

One of our admitting diagnoses is "Full term neonate with major problems". OK then...Have seen it on multiple charts...

An intern I remember fondly once wrote, "Condition: dire straights". (OK. it was the last day of internship! lol)

[peridotgirl]

for bladder retraining purposes, you can put a foley in to intermittent drainage.

what does that mean?

[Elvish, BSN, DNP, RN, NP]

peridotgirl said:

what does that mean?

example - someone has had a foley in for a while. once in a while, the bladder 'forgets' how to expand and contract to allow someone to hold their urine and then void when they want/need to once the foley is out.

to keep from having to I&o cath someone over and over in the hospital (multiple catheterizations = increased uti chances), you can leave the foley in but keep it plugged. every so often you can unplug the catheter and allow the urine to drain out. this retrains the bladder to expand (while urine is collecting there) and contract (while the catheter drains the urine out) at intervals. hence, bladder training.

back to the regularly scheduled thread. 

[morte, LPN, LVN]

what does that mean?

that the foley would be clamped, to "retrain" the bladder,

[Elvish, BSN, DNP, RN, NP]

Clamped, I mean. Clamped. Thanks for the clarification, morte.