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."

[sweetart_1980, RN, CNS]

not a blooper but funny:

for a end of life cancer patient who jokingly answered the question posed by the MD u need anything else to help u? she replied a couple shots of vodka would be great! The MD wrote the order 2oz vodka bid prn...way to go doc!

[Jessiedog, RN]

Gompers said:

A classmate in nursing school actually charted, "The patient pooped in his pants."

Good charting! Short, succinct, and relays the information needed.

[Jessiedog, RN]

Aaron86 said:

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...

'Pleasantly confused' is perfectly legit!! I've already decided that if I develop Alzheimers, I want to be the confused pt who's right off the planet, but happy and contented. They seem to have so much fun, and are GREAT to work with. Sure makes a change from those who are confused and angry, combative, aggressive, or disressed as a result of their disorientation. 

[talaxandra]

One of my friends says she wants to be intermittantly confused - lovely but dotty with the nice staff and a screaming, painting hell-cat when certain (less favourite) nurses on our ward are caring for her :)

[amyb2684]

I was doing a postpartum rotation a couple of weeks ago and my instructor pointed out to me that I charted. "Pt plans on bottle feeding, but will breast feed for benefits of meconium. While in room infant passed colostrum."

[jayne109, RN]

or

on the preop checklist in the belongings section "family took toilet trees home"

I have to ask-if you pick the toilet tree before the toilets are fully grown, do you get the baby toilets that you find for preschoolers and little kids?

HE HE HE:p

[izeofblu1973]

I always get a kick out of ...pt sleeping but easily arousable. I always want to write, "arent most men?" hehehe. I always write easily awakened.

[Not_A_Hat_Person, RN]

From a social service note "enjoys music, books, and squirrels in her room." I think they meant watching squirrels (through the window).

[adoptionacres]

One of our intensivists came to me one day laughing because she'd read this: "Dr. A popped by to see Baby J for a cuddle and a tickle." Another time I wrote in a teenage girls notes: "M engaged in spirited discussion with writer on merits of pink lip gloss over peach." The girl loved it. Don't know what our manager thought. 

One shift I had a 3 year old brought in to the ER for a tiny scratch on her elbow after a fall. I wrote the telephone order and charted for "a kiss and a band aid." Applied and followed by a response of "Patient tolerated well." The review committee loved it. 

[JWaldron]

These aren't charting but still funny...

When the pts are registered, the registrar enters the admitting diagnoses and most of them aren't versed in medical terminology.

We have many admitted with "Periferal Vascular Disease"...last week I had a patient with "Flue".

It always gives me a good chuckle.

I've seen adm. Dx like this too, and they make me laugh. how about Eurosepsis, or Baloney Amputation, two of my favorites!

Savvy

[chellelynn25]

Res is Double AKA ambulates ad-lib throughout facility, tolerates well.

[smileedee]

The new grad who documented in her initial note the patient had a history of a "cabbage". I just didn't know what to think. Not to mention the very old, experienced male nurse who documented "Patient crapped all night". I kid you not.