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:

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"Patient vehemently denies any auditory, tactile, or old factory hallucinations."

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Specializes in tele,med/surg.

I saw an ER report stating "Pt's vomit resembled chili con carne"

This was also a Hispanic patient.

I am Hispanic, I died ?

Did they really have to describe it as Chili con carne? LOL

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Specializes in tele,med/surg.

Another ER report was "Pt was like really puffy all over"

...lol

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Specializes in Emergency/Trauma/Critical Care Nursing.

I was precepting a new grad and came across a note they charted after giving an enema:

"Pt had two big terds and said she felt relief"

First we discussed what the proper terminology should be, then we discussed the proper spelling of turd. Lol

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Specializes in Acute Care, Rehab, Palliative.

I was charting on a physical rehab patient. I meant to say""patient encouraged to dress self". I typed "patient encouraged to dress elf".

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Specializes in ortho, hospice volunteer, psych,.
I was charting on a physical rehab patient. I meant to say""patient encouraged to dress self". I typed "patient encouraged to dress elf".

I don't know. I think elf dressing might be a useful skill at Christmastime. Think

of all the overtime!

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Specializes in ortho, hospice volunteer, psych,.

My mom was hospitalized for severe pneumonia. I had gone to school with her nurse that day. As I was leaving, the nurse showed me an admissions note the young nurse had written.

"Patient only has one boob." What? Huh? Really?

Maybe that's because she had a mastectomy while I was in grad school?!

BOOB? Try right BREAST!

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Under "reason for visit": Artificial mitro valve. Really? "Mitro" valve. Who put that in?

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Specializes in MICU.

"Subarachnoid hemorrhoid"

"Pt has been death since birth" (deaf)

By docs

I once saw another RNs charting as "removed pts clit ring"

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last night a secretary put in for frequency under vital sign " q * sh#t one of the nurses aids brought me a set of vs's at an odd hour and said "your pt just had a bm so i took her vital signs"

Now that's an awesome CNA!

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That transcriptionist needs to be fired.....lol

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"Wound irrigated with litters and litters of worm saline"

Op note for abdominal washout.

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