Charting Bloopers

Updated:   Published

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:

Quote
"Patient vehemently denies any auditory, tactile, or old factory hallucinations."
Specializes in Critical Care, Med-Surg.

In a post-code progress note by a cardiologist. "The etiology of patient's breast appears to be hypoxic in nature."

Ummm... I think he meant "arrest." Freudian slip ya think??

1
Up Vote Up Vote ×
As we were reviewing a chart on the Alzheimer's unit - this notation stood out:

"resident very agitated - yelling profound statements" Profane yes - profound no ..I doubt he was yelling "To be or not to be....that is the question...."

I'm dying!! Hahahahaha!!

1
Up Vote Up Vote ×

ER report stated "discussed plan of care with passerby" I hope that was an autocorrect error.

1
Up Vote Up Vote ×
Specializes in Critical Care, Med-Surg.

Not so much a blooper, but a very bad order. Nursing free-text order from a PA... "Please remind patient not to drink from his urinal."

You can't make this stuff up. 

1
Up Vote Up Vote ×

"Patient visible"

Inadvertent mashup of "patient alert" and "access visible" 

1
Up Vote Up Vote ×
Specializes in Hospice.

Admitting diagnosis on patients face sheet: Unstable lady parts.

Should have been Unstable Angina.

1
Up Vote Up Vote ×
Admitting diagnosis on patients face sheet: Unstable lady parts.

Should have been Unstable Angina.

Maybe it was a more clinical term for "****** be Crazy"

2
Up Vote Up Vote ×
Specializes in critical care, LTC.

More and more on H&P's, even on elderly ladies , we're talking 80's & 90's!

Not currently breastfeeding. Not a blooper. Must actually be part of the docs new charting process!

1
Up Vote Up Vote ×
Specializes in Critical Care, PICU, OR.

Pt. intubated, on vent.

Condition fair.

Plan of care discussed with patient, who verbalizes understanding

1
Up Vote Up Vote ×
Specializes in Cardio-Pulmonary; Med-Surg; Private Duty.

Many of our doctors use a speech-to-text program for their progress notes.

Many of our doctors are foreign-born, with the accents that come from not speaking English as one's native tongue.

Labetalol is not a word that speech-to-text programs recognize.

"Reduce libido to 200 two times per day."

Four hundred orgasms a day... someone's gonna need a LOT of K-Y!!!!

1
Up Vote Up Vote ×

One of my doctors types really fast as she's verbally explaining the discharge instructions. I can't tell you how many times she's said to "sue nasal spray". I keep telling her legal action is not necessary to relieve congestion!

1
Up Vote Up Vote ×
Specializes in Acute Rehab, Neuro/Trauma, Dialysis.

Went to a new pcp office as a patient. I was asked the typical screening questions, "Do you have any STDs, Hep B, Hep C, etc..." I started "no, but I work in dialysis so I am at a higher risk of exposure." The medical assistant makes her little note on the computer, I didn't think much of of it. I logged into my patient portal later and I see... "Sexually transmitted disease- risk noted- work related".

Has to be the funniest/most mortifying thing I have ever had happen!

2
Up Vote Up Vote ×
+ Join the Discussion