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."
Specializes in Med surg, Critical Care, LTC.

Ractated Lingers

"No complaints this sh*t." (shift)

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Specializes in Medical.
For a #: "Closed reduction internal fixation"

That's quite a feat!

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Specializes in mental health + aged care.

Yep. As the M.O. reading it said, "Interesting". Admittedly, that seemed to be his favourite word, lol

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Specializes in Med/Surg and LTC.
I once picked up a pt from LTC who pulled out and damaged her PEG tube. The narrative area on the transfer sheet stated, "PEG tube busted. Please replace."

I also once saw eurosepsis and hyperpotassemia written in a chart.

What the??????? Lol.

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Specializes in ED/ICU/TELEMETRY/LTC.

I swear, absolutely swear: Red, blancheable area at top of butt crack.

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Specializes in Geriatrics, Home Health.
I swear, absolutely swear: Red, blancheable area at top of butt crack.

Have you been reading my charting?!

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Specializes in ED/ICU/TELEMETRY/LTC.

LOL, just in case anyone wants to know, it's gluteal cleft.

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Specializes in Nephrology.

When reading one of the dictations on a patient with a buttonhole being used for hemodialysis I read, "pt currently using BUTTHOLE on left upper arm AVF". LOL! We were laughing about that one for weeks!

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AsatruRN said:
"catheter exit site positive for gram positive cock site"

oh no! seriously? ya gotta watch out for those bad boys!

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I'll admit to one of my own charting mistakes....

The computerized charting in our facility uses a standard assessment form for PT, OT, & Skilled Nursing, so we have to list the department for which we are charting. And, thanks to my mediocre keyboard skills, skilled nursing became:

"Killed Nursing"

I'm never going to live that one down....:grn:

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Best one I have seen:

"PRN Tylenol deemed effective. Pt no longer suicidal."

That is great stuff that tylenol!

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Yesterday, at the hospital, I was reading a patient's H&P. The following was charted:

"The patient is homeless, severedly depressed and was talking to his hands. He is incompetent of urine. He was admitted from jail but the reason he was incinerated is unknown."

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