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."

[brillohead, ADN, RN]

sharpeimom said:

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

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

Having just finished my psych rotation, I'm a firm believer that nanda needs a "coocoo for coco puffs" diagnosis.

[CJ NV]

Another medical chart bloopers."Pt.complaining of headache.Tylenol given as ordered.Checked back with patient one hour later and head gone."

[lynhardworkingrn]

Here are a few:

Medical orders and advice:

May have lollipops orally.

She is to refrain from sexual intercourse until I see her in the office.

For his impotence we will discontinue the meds and let his wife handle him.

MD order: May shower with nurse

She can begin to use the lawn mower, but no lady partsl entrance.

[CrazierThanYou]

This isn't a blooper but we have a resident who has doctors orders for "Pats on the back twice a day".

[sharpeimom]

My husband had foot/ankle surgery done and a nurse friend shared a charting goof on his chart with me.

"Change rt. foot and ankle dressing q 12 hours.... rt. AKA on December 12...."

Just one question. How the heck do you change a foot and ankle dressing on NO foot or ankle?!

I guess his foot and ankle just spontaneously regenerated.

[GitanoRN, BSN, MSN, RN]

sharpeimom said:

Just one question. How the heck do you change a foot and ankle dressing on NO foot or ankle?!

I guess his foot and ankle just spontaneously regenerated.

Ooops!

[FurBabyMom, MSN, RN]

Just one question. How the heck do you change a foot and ankle dressing on NO foot or ankle?!

I guess the same way a bilateral BKA patient has pedal pulses, heels elevated, bilateral knee high scds and teds on and the correct color socks indicating fall risk on their feet. One nurse I used to work with chatted all those...

[amoLucia]

CrazierThanYou said:

This isn't a blooper but we have a resident who has doctors orders for "Pats on the back twice a day".

I guess he needs burping for an indigestion dx! 

[Indy, LPN, LVN]

"Pt family pureed foot and fed it to him and he ate it all"

The handwriting on it was very neat, it was clearly f-o-o-t not f-o-o-d.

[Penelope_Pitstop, BSN, RN]

"He urinates from his urethra and also drinks from his suprapubic catheter."

Hmm, somebody didn't correct his consult after dictation...

[DSkelton711]

I saw a nurse chart "wound has ***** drainage" in a nurses note. lol. I have a dirty mind, I know.

[Anna Flaxis, BSN, RN]

^ Same as above. Instead of "pus-like" drainage.....