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."

[Spritenurse1210, BSN, RN]

Alright, I'm going to put on my big girl panties and admit to this one:

Patient resting in bed with eyes open WASHING TV!!

ooops........Needless to say, after a cup of coffee i was able to correct that little gem really quickly!

[kat von b]

This happened years ago when I worked on a general surgery floor. A med student had to do an admission physical on a rather voloptuous young woman. On the assessment sheet under "breasts" he wrote "Big and beautiful."

Needless to say this med student got his posterior cooked by the staff doc.

LMAO!!!!!

[RNstudentforlife]

One day, when I was a nurse in training, I was busy charting and did not realise that everytime I spelled the word assess in our computerised charting, I left the second s left off the end. My charge nurse got a good laugh and told me to take the asse_ out of my charting!

[jaybenRN]

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.

oops just browsing and this user doesn't know what Kay Ciel is... ^_^

and someone even agreed with her telling about another person

who used the term..

[Elvish, BSN, DNP, RN, NP]

Kay Ciel = KCl = potassium chloride.

[kanzi monkey]

Jay-Jay said:

I think it's posted elsewhere on this site: the physician couldn't think of the correct name for the incentive spirometer, so he wrote: suck balls QID! 

I know this post is now more than 7 years old. However, I think it's very important that we all know that once a physician ordered for a patient to "suck balls 4 times a day"

Yay for this thread and more than 500 awesome bloopers! Read and be happy!

[kanzi monkey]

fiveofpeep said:

one grumpy anesthesiologist wrote for a diabetic patient under orders "give her something" ... no scale or type of insulin specified... how classy

NIIIIICE. The mystery of medical doctoring is solved. Defer to the nurse.

Tee hee 

[tinerjayne]

Written on our Cardiologists Progress Note today: Pt has end stage constipation.

I kid you not!

[exnavygirl-RN]

A very common abbreviation used at my facility is NAD (No apparent distress). We have a nurse that constantly charts " No NADS". I asked her one day why all of her patients were missing testicles. She gave me a confused look. Love her to death but....

[HDNurse]

I work with a very sweet asian nurse who always charts that the patient has 4+ pitty edema. Having that much fluid in their legs, I feel sorry for them too.

[horrorxgirl]

I have a few. I used to work with an RN who was constantly charting bizarre things. She at one time had to clean up a patient who had managed to get BM all over their body, and mostly on their stomach. She charted it as: Fecal material in Abdominal cavity...

She also one time wrote an order for Toxic water instead of Tonic Water for a patient who drank it for leg cramps.

And now I'm going to make fun of myself.

I work midnight shift, and when I have slow time, I will stock the charts with blank physician order sheets. I write the Patient name, room number, our facility name, and patient allergies at the bottom of each new sheet. Well I have a home cake business on the side, and apparently one night when I was stocking charts, I must have had a cake on my mind that I was going to do because I managed to somehow replace on the words in our facility name with the word "fondant". The bad thing is that I didn't catch it until the next week and the sheet had already been used to write new physician orders and had been faxed to pharmacy a few times. Nobody else had caught it, haha.

[Jamesdotter]

A colleague once told me of an order to "watch patient" (said patient was in congestive heart failure). As she said, "I had 30 patients that night with one aid. I watched him run down the hall, out the door and down the street ..." She called security who caught up with him 2 blocks away.

Thirty patients was a fairly standard assignment, with usually 3 total staff--but they weren't as sick as they are today--many if not most could be relied on to sleep much of the night.