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."

"Discussed with the patient dangers of living AMA..."

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Specializes in Hem/Onc, LTC, AL, Homecare, Mgmt, Psych.

OK I have 2 for you

An excerpt from a chart: "Pt c/o pain OU feet"

I had to tell the nurse that OU meant both eyes and not plain old bilateral

And...

So, you know Ankle Foot Orthosis = "AFO"

After seeing "FAO boots in place" over and over I told the nurse FAO is the toy store,

AFO stands for something different!

:nurse: We love our abbreviations, don't we?

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Specializes in Care Coordination, MDS, med-surg, Peds.

i saw where a PN student wrote, in a chart....Iv INFILTRATing as ordered.. hehe

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Specializes in Long term care.

I have a couple:

On a Nar worksheet someone wrote "sitting in the Recylinder" hehe....

and on the same day one of the very confused patients was on a kick about thinking that they were being killed,etc....but the nar wrote "very, very, angry KILL"....it was a good chuckle....obviously it was a statement of what the patient was really angry about...but it was humorous.

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just read this one: Allergies: contrast dye, asa, lasix and SELFISH.

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Specializes in ED.

I had a chuckle this morning when the MD drew a rooster in the orders lol

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And I love the 'balony amputation' I've seen a couple of times. It fits right in w/ Eurospesis. Gotta love those folks in Admitting. Oh, that's right, it's called 'Patient Access' now, whatever that means.

Savvy

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Pt is currently 15 months pregnant 

(I work in psych )

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I'm only a 2nd semester nursing student, but yesterday at clinical on a patient's chart I saw this.... "Drug Allergies; Ketchup"

Like I said, I'm still a student so there might be a drug called ketchup that I haven't heard about yet, or something I haven't learned about ketchup. but I got a giggle out of it! :)

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I work at a skilled nursing facility and was helping with an admission when we came across an order written by the MD in the hospital that said "stop smoking or you'll lose your leg" although the intention was probably good the wording made us all laugh really hard.

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ClariceS said:
I recently saw a "add 20 mEq Kay Ciel to existing IVF" order also. Maybe these docs were trained at the same place.

We also had an order recently that to us really brought into question the integrity of the writer. The order was for "1 baked potato p.o. bid". First, where else would a baked potato go  and secondly, dietary requests do not need to be written by a doc in the orders sheet!

[This message has been edited by ClariceS (edited December 27, 2000).]

That has to be the funniest thing I've read in a long time ? I laughed so hard I started coughing! ? eep, hope I'm not sick!

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Specializes in ICU, ER.

Not a blooper, but it gave us a night full of laughs! I had been off the night before and my preceptor had taken care of my assigned pt. He was shipped to another hospital for a procedure, but we weren't sure if he was coming back to us or not that night so I was reading up in case he did.

The intensivist wrote: "x year-old pleasant gentleman, previously lady."

My poor preceptor was thrown for a loop! Apparently the pt had refused to take his pants off, now we knew why!!

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