Charting Bloopers

Nurses Humor

Updated:   Published

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 ICU, HD,Mgr, Supervisor,Tele,.

hey guys, P***y is actually a term used to describe purulent drainage. Learned that last year when i got wound care certified.

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Specializes in ICU, HD,Mgr, Supervisor,Tele,.

I was working ER one night. The Ortho tech/ward clerk took a EMS radio call. Pt stated she "had vines coming from her Virginia"

Seems the patient had uterine prolapse & used a sweet potato to "push " it back in. Needless to say the ERP documented this & that she truly had "vines coming her Virginia" The warm moist environment made the sweet potato sprout! wonder how long she left it there? I did not see it but I wonder how long the vines were & how she used the bathroom??????

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Specializes in general medical.

(not really on charting)

a watcher came to the station saying:

"Grandma VERBALIZED she's constipated"...

I, and my Nurse Aid frowned, then smiled...

just so happened that GRANDMA had a tracheostomy. 

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

when I was a pt, I heard on the intercom another pt talking to the nurses station: "I need a cough suppressant so that I can suppress my cough.." Next thing I heard was the giggle of nurses!!! Hit 'em funny, I guess.. :}

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Specializes in Trauma/Tele/Surgery/SICU.

Not really a charting blooper but made me crack up laughing.

We had an admit from ER earlier in the night (not my patient Thank god!) Drunk, combative, c-spine precautions refusing everything, cussing out the RN, taking the collar off and throwing it around, threatening to kick everyones butt, just a real PITA pt. My co-worker spent most of her night on the phone with docs and charting his behavior.

That a.m. I just happened to be sitting at the computer when the attending for this pt. sat down next to me and began dictating, and I quote:

"Pt. is a total piece of s$*%, being a total a*&&^%e to the nurses, threatening to leave AMA and I hope he does"

I never laughed so hard in my life.

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I love transcription errors. I laughed one day when a doctor's note said "she experienced an access her basin." (yeah...exacerbation...)

thanx everyone for making me laugh until I cried - and just when I calmed down, I read the next one and started again!

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Specializes in mental health + aged care.

This patient is in a long term rehab psych service and had gone into hospital for a colonoscopy. I saw this written in her notes...

"Mood settled and appropriate, although she did ask the radiologist if the tube being inserted into her bottom was going to turn her into a Maori princess. Reassured it wouldn't. ___ in positive mood on return to ____"

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Meryea said:
I was working ER one night. The Ortho tech/ward clerk took a EMS radio call. Pt stated she "had vines coming from her Virginia"

Seems the patient had uterine prolapse & used a sweet potato to "push " it back in. Needless to say the ERP documented this & that she truly had "vines coming her Virginia" The warm moist environment made the sweet potato sprout! wonder how long she left it there? I did not see it but I wonder how long the vines were & how she used the bathroom??????

She came to my ER too! >laugh

Savvy

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Specializes in critical care, home health.

I work with a nurse who collects hilarious charting bloopers. When I find one, I put a copy of it in her mailbox (with the patient's name and other ID info blacked out) for her. She does the same for me because she knows it always brightens my day.

The most recent one: under drug allergies, the patient had listed CARDIZEM because the reaction was "Makes me feel crappy".

Apparently not too crappy, because the patient was on a cardizem drip.

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On computer charting I caught this before I saved my note and was able to correct it:

Client has a large *ss on left posterior thigh.

Thank goodness I was able to change that to "mass"!

When I worked in a hospital I would always find "pedal pulses strong" on bil BKA's or VS charted on patients that had expired hours before, or bil lung sounds clear on a pulmonectomy client. Amazing!

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Green Nurse said:
On computer charting I caught this before I saved my note and was able to correct it:

Client has a large *ss on left posterior thigh.

Thank goodness I was able to change that to "mass"!

When I worked in a hospital I would always find "pedal pulses strong" on bil BKA's or VS charted on patients that had expired hours before, or bil lung sounds clear on a pulmonectomy client. Amazing!

Your post reminded me of the time I got 'corrected' for a data entry I DIDN'T make - and it would have been pretty strange if I had. I had a patient who was a left BKA and a right AKA, and I didn't enter a height for him! Should I have entered his current height? On his right side or on his left? Or his reported height before the first surgery, or before the second? (I just got a dirty look when I asked )

Savvy

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on an OB addmission assessment while I was doing my maternity rotation for RN school I came across this:

Pain scale: 8 Location: Husband.....

Me, my fellow classmates, instructor, and the staff nurses laughed for a good 5 min on this one..

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