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:

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"Patient vehemently denies any auditory, tactile, or old factory hallucinations."

Just posting so I can follow this thread. It's a nice change from the usual stuff.

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Specializes in MED/SURG STROKE UNIT, LTC SUPER., IMU.

I am with you. I want to keep up with this thred also! Seriously funny!!!

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As a nursing student, I was reviewing for clinicals the following day. I was reading a H & P on a patient from an intern. The intern stated the patient had a TURP in 1995. The patient's a female.

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Specializes in Respiratory, Med/Surg.

Like many of these, this is not exactly a charting blooper...

My wife and I were in a car accident. We both felt a little sore, so we went to the ED, just to be safe. I got a little confused when they took my wife in for an x-ray, but never did one on me. They car was hit on her side, do I just left it at that and didn't think much about it. Then, when we were d/c'd, we saw that they gave her information about spinal injuries. It didn't make sense. And then it hit me. When they asked about past medical history, she told them that she had a cirvical cerclage (an OB procedure). They heard cirvical and assumed cervical spine. Impressive that they know their body parts. 

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Specializes in rehab and some telemetry.

at the end of my third 16 hr.(3p-7a shift) shift in a row I had mistakenly written an exerpt something like this: Res. slept well...stated she had a great night dancing with her husband...

mind you it was the middle of the night and she was in rehab with a fresh hip and nwb status.:smackingf

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Specializes in Med/Surg, Ortho, ASC.
As a nursing student, I was reviewing for clinicals the following day. I was reading a H & P on a patient from an intern. The intern stated the patient had a TURP in 1995. The patient's a female.

Are you sure the intern didn't say TURB?

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Specializes in Med/Surg, LTC, Rehab, Complex Care.

Patient had six litters of fluid drained (That's a lot of kittens!)

Doctors ED notes, "Vitals stable, BP xxx/xx T xx R xx P 1000.....(What!?!)

Saying goodnight to patient and she replied "Have a nice vacation" (Will do, I'm out)

I'll try to find more at work tomorrow night! He He

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Specializes in Med/Surg.
NuteRN said:
Like many of these, this is not exactly a charting blooper...

My wife and I were in a car accident. We both felt a little sore, so we went to the ED, just to be safe. I got a little confused when they took my wife in for an x-ray, but never did one on me. They car was hit on her side, do I just left it at that and didn't think much about it. Then, when we were d/c'd, we saw that they gave her information about spinal injuries. It didn't make sense. And then it hit me. When they asked about past medical history, she told them that she had a cirvical cerclage (an OB procedure). They heard cirvical and assumed cervical spine. Impressive that they know thier body parts. 

I am not sure what you mean by "cirvical cerclage," exactly, but cervical is spelled the same in both areas of the body. What is "cerclage?"

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Specializes in Med/Surg, Ortho, ASC.

"What is "cerclage?" Cerclage is a procedure (involves a suture, I believe) used on a pregnant woman with an incompetent cervix. It helps keep the cervix closed until delivery time.

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Specializes in MED/SURG STROKE UNIT, LTC SUPER., IMU.

Cerclage: also called purse stings (for slang) because that is what the suture stitch looks like. It is used to keep the cervix closed until it is time for delivery, otherwise if the cervix is not strong enough the baby will be born prematurly.

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From last night, the triage nurse wrote: ROH. According to friend consumed unknown amounts of speed and coke. Responds to pain and alcohol.

I write my notes in French and don't understand all the abreviations here. I feel I'm missing out on some funny stuff.

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Specializes in Med/Surg.
roser13 said:
"What is "cerclage?" Cerclage is a procedure (involves a suture, I believe) used on a pregnant woman with an incompetent cervix. It helps keep the cervix closed until delivery time.
TonyaM73 said:
Cerclage: also called purse stings (for slang) because that is what the suture stitch looks like. It is used to keep the cervix closed until it is time for delivery, otherwise if the cervix is not strong enough the baby will be born prematurly.

Thank you for the info. I did not know what cerlage was; I haven't ever worked in OB beyond my brief rotation way back in nursing school. I also didn't know what "cirvical" was.... 

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