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."

[Punkrocksn]

lmao, I was about to say something then realized you were talking about NICU baaa ha hahha!

[Punkrocksn]

A fellow student was watching her first woundvac on her patient with WCN. Before wound care left, she asked if the student had any questions. The student says, "I noticed something in her perineal area... I don't know how to describe it... CORAL?"

The patient had external HEMORRHOIDS

[Jtsqueek]

How about " patient is on continuous Lasix infusion running at .... And has an indoor pool" in my defense it was about 2am :-)

[NancyPie]

I work in a facility that has recruited nurses from puerto rico to staff the building. Most of them speak little or no english, and as you can imagine the charting is quite difficult to make sense of. I think the most memorable thing I saw was a pharmacy return sheet where the reason for return of meds simply said "PT DEAD"

Working in a nursing home, I've had to return meds for this reason. I always write Patient discharged. At least she was clear? x'D

[GM2RN]

I once saw a pap smear ordered on a man. Does that actually exist somewhere? I thought it was pretty hilarious. And, no, the pt was not a transvestite or a hermaphrodite.

We get this occasionally in the ER with computer charting. The docs have order sets to choose from and will sometimes forget to uncheck the urine pregnancy test for males.

[Kay28]

Here's my favorite I saw yesterday. I had a patient who had a translady partsl ultrasound. The radiologists impression was, "No testicular torsion."

[Penelope_Pitstop, BSN, RN]

We had a patient who required an MRI, but had nipple rings of the bar variety that I guess hadn't been removed in some time. Well, she couldn't get them out and wasn't interested in having any of us try. The physician, who is a personal friend of mine, was trying his darndest to get her to go through with it. He wrote "discussed with patient the merits of removing nipple jewelry."

Not a blooper because, well, that's what he meant, but it was still hilarious. We did get them out with pliers, by the way. She was actually a pretty cool older (yes, older!) gal. She had absolutely beautiful tattoos and her husband smoked pot to chill out with their adult son.

[Krissy,RN]

H&P describing a lady partsl exam and pap...Patient....a 2 year old boy??

[Etone LPN]

May not have been incorrect charting as foley catheters have been used in a pinch to control intractable epistaxis. I have heard of this practice before but have not seen it used. Makes sense though as a foley inserted into the nose and the balloon advanced to the source of the bleed, the balloon inflated would compress the vessels controlling the bleed.

Medscape: Medscape Access

Another application of the foley catheter is ... a #30 fr. foley catheter can be used to replace a G-tube that a patient has yanked out. Have done this twice myself. Pt never missed a feeding! Do understand that the practice of using urinary catheters would be a big "no no" now for these purposes due to liability factors, as this is not what the manufacturer intended.

Would look funny seeing that documented in the nursing notes though ... ?

[kanzi monkey]

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

That was probably me

[purpurata]

In reading a patient history, I noted that he had a history of BKA. The exam went on to say right pedal pulse 2+, left pedal pulse 1+. I wondered how he had bilateral pedal pulses when he'd had an amputation. Going further into the notes, along about the time the doctor was discussing the glucose level of 500, it became clear that it should have said DKA, not BKA. Slight difference there... 

[meanmaryjean, DNP, RN]

I was charting at about 0330 once, really struggling to stay awake. Had to re-write the entire page after I wrote this "Code Blue, room 2226, Code Blue, room 2226, Code Blue, room 2226" I was writing what was coming over the paging system.

The worst part? I was on the code team! (I eventually 'came to' and responded to the code - which was actually someone vagal-ing after a blood draw.)

NEVER lived that one down.