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."
crissrn27 said:
Hi, new user, just found this website, it's great! Anyway, had to share this story, not a chart blooper, but a huge blooper anyway. Years ago I was an MDS nurse in a SNF and the state was making rounds with one of our (masters prepared!) floor nurses on his med rounds. The nurse noticed the pt needed honey thicked liquids, so he insist (to the inspector with him) that he must go to dietary to get honey to thicken the liqiud! needless to say we did not pass inspection that day

ha-ha ?

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these aren't charting bloopers-- but I work in ER, and working triage quite often, I'd like to type just what the patient tells me.

Examples: 80-ish yr old woman tells me she saw blood in the toilet but she didn't have a bowel movement so she doesn't know if it came from her rectum or her "majina" "janiva" "whatever its called" hahahah!! she was so cute.

"I have fibronalgia and its acting up"

"I think my prostrate is enlarged" (hear that all the time)

"I was out in the sun yesterday and now my face is swollen and I'm afraid my throats gonna swell shut" now correct me if I'm wrong, but I really can't see that one happening!???

A girl I used to work with was joking around and typed in " I am a sl*t and I like to ***unrepeatable*****" and was showing it to another nurse and accidently hit file! We can "undo" documentation but it still shows up in the chart, just has "undone" after it! Ahhh, watch what you say!

I work nights and it can get pretty hairy after working a few in a row. One RN actually started typing about her dreams!! Fortunately she woke up and erased it!! I find myself writing about what people at the desk are talking about when I'm tired. Happens to us all! I'll often call report to the floor and go, oops, I charted that the IV is in the LAC, but really, its in the RAC. (dyslexic maybe?)

And my personal pet peeve is one nurse who's first nursing note is the SAME for every patient, no matter what the heck is going on with them. "resting in bed, resps easy nonlabored lungs clear abd soft nontender skin fleshtone dry alert and oriented." Just like that, no punctuation, etc. His assessment then reads "unconscious... or rhonchi heard throughout, etc" HELLO?! Try to defend all that in court. 

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Specializes in Medical.
I work nights and it can get pretty hairy after working a few in a row. One RN actually started typing about her dreams!! Fortunately she woke up and erased it!! I find myself writing about what people at the desk are talking about when I'm tired. Happens to us all!
A friend fell asleep while writing her notes and woke up to find she'd written "I know that you can see me"!
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Zee_RN said:
...in an H&P...."hx of lady partsl hysterectomy for hemorroids."

Oh yeah?

Hey, no fair, my hysterectomy didn't take care of my hemorroids!

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Specializes in PACU.

In a hospitalist's H&P: the chest x-ray showed bilateral ankle fractures.

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Specializes in Intermediate care.

I admitted a patient whose diagnosis was "Sick"

....hm?!? Really now??

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Specializes in mental health + aged care.

In a physicians notes: "Wound is healing well but a screw is loose." We're assuming he meant the metal ware, but you can never really tell

My own notes (same day): Pt "Not initiating eating herself"

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nurse-to-be1000 said:
Actually I just heard about this very way of giving karo syrup to a diabetic dog this morning on I believe Good Morning America or the Today show (relaxing due to being snowed in). The suggestion was to put the syrup in a syringe and squirt it between the dog's cheek and teeth so it would run down the back of his throat. However, I admit I do not have any animals so I don't have any first hand experience with this but I wouldn't want to try it.

While working in a SNF, I had a truly delightful gentleman who was an insulin dependent diabetic. It was quite common for this guy's pre-breakfast blood sugar to be in the basement. He was not rousable for eating or drinking, (not uncommon for blood sugar to be around 30!) My method with him was to get a squeeze bottle of pancake syrup from dietary, squeeze some between his cheek and gums, and initiate a reflexive swallow. He'd respond quickly and then would willingly eat half a peanut butter sandwich. Being in a rural area, his Primary doc was a dork who wouldn't evaluate why this gentleman was so up-and-down. After multiple, multiple, MULTIPLE discussions with this doc, he finally agreed to a sliding scale. For all these bouncing blood sugars, the gentleman had no residual damage.

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post-op patient woke up with complaint of 'smelling like diesel' pain meds reduced no longer smelling like diesel but would like it back?

the patient was not confused at all at the time.

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Specializes in allergy and asthma, urgent care.

In chief complaint, "76 y.o. woman complaining of difficulty breeding"...... you think????

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radiologist interpretation of an abd series... "funny looking cecum" I mean, really??! Maybe it caused him to chuckle...

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Specializes in mental health + aged care.

For a #: "Closed reduction internal fixation"

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