Charting Bloopers

mgthompson · Sep 29, 2001

Transcribed dictation is a constant source of hilarity for me.. on the OB floor: "Gross fecal movement noted" (the doc said "fetal").. or on lady partsl exam: "small bloody shell" (that would be "show" - I haven't seen one hatch yet.. )

kaycee · Oct 1, 2001

One of my co-workers wrote this in her triage assessment the other day.

Patient is illegally blind.

panda_181 · Oct 1, 2001

I read these and always laughed my head off at some of these, and this weekend I found some of my own!

I was reading 2 dictations from consultations from 2 different doctors. One was about "a very pleasant lady sitting down and in no apparent distress". Now, does this mean that she's cranky when she's standing or lying? I'm not quite sure...

And the other was about a child, whose symptoms of autism are "moderately severe". Can you put those 2 words in the same sentence? I thought it had to be one or the other...but maybe that's just me...

Amanda :)

SweetnesssssRN · Oct 1, 2001

a nurse copied the admit orders for a pt with a foley and she added: INPUT & OUTPUT

she later told me: "I think I've been spending too much time on the computer"

shannonRN, BSN, RN · Oct 22, 2001

hilarious thread. keep em coming!

I used to work on a rehab unit and we had an 18 year old with head injuries from a mva. well, he had decorticate posturing. one of the psychiatrists wrote that the patient had "rabbit syndrome!"

robinday · Oct 22, 2001

I review charts and come across bloopers quite often. Some of my most recent:

60 y.o. male with known cirrhosis and portable HTN.

Family decided on a no code stasis and thought it was time to discuss the femoral.

Pt. knows the time and space.

Family history: mother had CA, sister had a sore on her leg.

Past surgical history: significant for multiple seizures to her ear drum.

Paul is a 74 y.o. gentleman who is older than his years.

IV Nafcillin will be started on the basis of quality of staff (sic) coverage and penetration of the CSF.

She had felt reasonably well over the last week when she had the sudden onset of shortness of breath while driving her coronary artery.

Arrangements were made to transfer the pain to another hospital where he was to have coronary angiography.

Isn't this a funny business???????????? :))

debbyed · Oct 23, 2001

Doctor was charting on a patient with abdominal pain. The patients name was Paulette. "Patient denies pregnancy, denies hysterectomy but states has never had a menses. Plan: Beta HCG and pelvic exam" I would have really liked to be in the room when that physician tried to do a pelvic. You see Paulette was a frequent flyer whose birth name was Paul. He actually looked like a very beautiful woman, but at this point had not had any sex change operations, only hormones.

misti_z · Oct 23, 2001

These are really funny!

In a docs H & P he wrote 'This is a 88yo BM' BM of course for black male.....well......he dictated his note & the finished product read 'This is a 88 year old bowel movement'. Talk about old pile of $hit......just kidding

stephi57 · Oct 25, 2001

At change of shift, 5 RNs, 3 LPNs and the nurse manager huddled over a chart where the pediatrician had just ordered what appeared to be "TL". All that combined nursing knowledge could not decipher what TL could possibly stand for. :confused:Finally we admitted total ignorance and called the doctor. Aha!! His rushed handwriting had caused his "TC" for throat culture to look like TL!!!!!

Moral of the story--beware of abbreviations!

NurseDennie, BSN, RN · Nov 5, 2001

How about "patient D/C home in wheelchair, voiding excellently."

I LOVE that one and giggle about it at odd moments (and yes, I do have quite a few odd moments). It conjures a mental picture of the little fire boats welcoming a big ship into harbor - all those water jets spraying into the air.

Love

Dennie

shannonRN, BSN, RN · Nov 5, 2001

just last night I was reading a doctor's h&p...well, the last three words were pleasant octogenarian female?!?!?!?! yes the patient was 88 years old, but a generation every ten years? maybe he meant octagedcadarian?!!

LynniNurse · Nov 17, 2001

We often infuse antibiotics thru a 3way foley that then drains to a bedside drainage bag -- it's called a bladder irigation. Mostly seen with amphotericin B but sometimes even with Vanco. It's really no different than when the dialysis team uses antibiotics to wash thru the patient.