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."

[NancyPie]

DutchgirlRN said:

Pt telemetry alarm going off at desk repeatedly, pt sleeping w/o any distress noted, telemetry turned off at the desk.

This patient was found dead during the 0400 v/s. Needless to say, this stupid nurse lost her license and the hospital is involved in a lawsuit.

OMH! OUCH ... wow.... GASP...

[nursenonblonde]

I was a brand new nurse. I had a patient with a very bad burn the entire length of her arm with puss pockets. Unfortunately...I charted...Pt has Pu**y drainage to entire length of arm.......no one noticed but the Dr.

[sairin8]

Problem list

Never smoked tobacco

[nursebellamy]

Although I know this was a transcription error, it still made me laugh. "Pt is hard of hearing and wears bilateral hearing autoimmune deficiency syndromes". Also, in another chart, a doctor had transcribed in his notes something to the effect of ... "...Upon digital insertion into the pt's rectum, tonsils appear to be normal in size and structure." WOW, That is some long finger!!

[Start2]

Too funny!!!

[britgirl37]

How about "contented demented" instead of "pleasantly confused" !! I've heard that in a handoff report a few times!

[Davey Do]

A young lady was trimming branches when one of the branches flipped up, striking her between the legs. She developed a hematoma of a labia. An OB/GYN excised the hematoma. He was dictating his note and stated,

"The patient had been struck by a branch between the legs."

The Medical Transcriptionist had difficulty understanding the statement due to the Physician's thick accent. So she typed,

"The patient had a stroke on a bridge between two lakes."

Dave

[purpurata]

not a charting problem, but this was the text of an x-ray report: "views of the left elbow were taken which show a third finger pip dorsal dislocation with slight ulnar angulation."

I wonder exactly how many fingers he had in his elbow? 

[AsatruRN]

"catheter exit site positive for gram positive cock site"

[kmonwiler]

I am a home health nurse, I called Med Records to find out what one of my patients had been admitted to the hospital for....the non-medical person who answered the phone informed me that my patient had been admitted for hyperchlamydia. Stunned by this as my patient was not really someone who would have this nor would they have a HYPER version, I asked her to spell it for me....she spelled H-Y-P-E-R-C-A-L-C-E-M-I-A. Laughing I said ok thanks but that is hypercalcemia, much different from hyperchlamydia....

[FC RN BSN]

In nursing school, one of my fellow students wrote that a patient had a pulse grade of 2 for his posterior tib and pedal pulses. Too bad the patient had both of his legs amputated many years before he was on the unit...whoops. And here's your sign. 

[mr_nurse_drew, ADN, BSN, RN]

FC RN BSN said:

In nursing school, one of my fellow students wrote that a patient had a pulse grade of 2 for his posterior tib and pedal pulses. Too bad the patient had both of his legs amputated many years before he was on the unit...whoops. And here's your sign. 

I've seen charting errors like this one done many times, and not by students but experienced RN's....scary, huh?