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."

[GitanoRN, BSN, MSN, RN]

many moons ago i received a verbal order from a doctor, well i got distracted and while charting i wrote the following "pcp order verbally via phone= "pt. may shower with nurse"..... i'm still living up to that one

[Intentional]

one of my favorite nursing notes explained how a confused little old woman had "vomited whole pineapple" during dinner. the image of a whole pineapple, leaves and all, coming from this lady's mouth had us all laughing pretty good!

[Christy1019, ASN, RN]

I had a male patient in the ER with a submandibular and paratonsil abscess that ended up being nasally intubated for airway protection... later, I was reading the radiologists report of the pt's head/neck CT which stated:

"lady partsl fluid noted in the danger space"

Ummm... say what?!? Lol

Sent from my SPH-D700 using allnurses.com

[mariebailey, MSN, RN]

I was charting in a deceased client's record; the client had a communicable disease. instead of writing, "contact of client agreed to arrange repeat tuberculin skin testing next week", I wrote "client agreed to..."

[sharpeimom]

gitanorn said:

many moons ago I received a verbal order from a doctor, well I got distracted and while charting I wrote the following "pcp order verbally via phone= "pt. may shower with nurse"..... I'm still living up to that one 

Where do I go to sign up and do I get to choose the patient?!

I would think that in psych and forensics that might work out better! (for me anyway!)

[Zatara142]

Intern charted that the attending's plan was to "Monitor eyes and nose" on patient with heart failure. What he'd said was "I's and O's.":icon_roll

[RunninOnCoffee]

Admit orders from the ER written my MD.... Admit pt, dx hypopopotassiumemia???? How about hypokalemia?!?

And my own error that luckily I caught before I hit save.... mepilex applied to buttcocks!! Oops! Never heard of one of those in A&P!

[jjrodriguez, BSN, RN]

My first semester of nursing school, my clinical-mate's patient's diagnosis was "SICK".

[anon456, BSN, RN]

I work in a peds hospital and the patient list will give a brief description of why the patient was admitted. One said "Accidental medication indigestion."

[dirtyhippiegirl, BSN, RN]

So. I'm taking care of two patients one night - walky talky 20-something post-op floor pt who is only in for a 23 hour obs and an elderly, ICU status lady with multiple cardiac issues.

During my shift, elderly lady gets made a DNR, has a sixty second run of vtach (totally asymptomatic btw), starts throwing PVCs secondary to a "minor" MI which we then started her on a heparin drip for, and has an acute CHF exacerbation requiring lasix and morphine and a lot of hand-holding.

I put everything that happened in a single narrative note and forget about it.

So, early the next morning and towards the end of my shift, the medical student approaches me with this huge, saucer-like eyes and stammers: "So...WHAT all happened with Mr. Jones last night? I was reading the notes and..."

I'm just glad that it was the medical student who caught my mistake and not someone else!

[GitanoRN, BSN, MSN, RN]

many moons ago, I recall working the night shift and as the shift ended I was on the last of my charting. obviously, I got a little distracted when I charted the following " mr. jones a 52 yr. male c/o of eggs, milk, cherrios, dog food" :uhoh21: needless to say, I was thinking of my grocery list, of course my colleagues never let me live that one down 

[sharpeimom]

A very very tired psych resident's diagnosis... just plain nuts.

Unfortunately, I wasn't working when the attending came in. Darn it all!