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."

[Jay-Jay, RN]

Uh, that's true, Lilli, but if you read a little further down the thread you would have found out the patient was a little old lady with SOB....

I loved the response to the above:

"Maybe that explains the SOB. Should have just straight cathed that nare!.....":D

[Cubby]

While working at our local Psychiatric Hospital many years ago (when nursing was still fun) I had a patient who had lost his shoes a few days prior. Well this particular day he was acting odder than usual so we checked him for an impaction. It was charted like this 'Checked for impaction, shoe found' OH MY!!!

[fedupnurse]

In a recent H&P: The patient has a history of alcohol abuse and an accident while in a coma.

Our unit secretary took off a Diprivan order as Tritrate to seduction.

On an axid order she wrote Acid 150 mg PO BID.

We had a neurologist called in for a pt. with a head bleed. The doc realized he had met this patient earlier that day when they had a minor MV accident with each other. His 3 page consultation detailed the entire fender bender and what they did afterwards. Maybe 2 lines were about his assessment and plan!

Another nurse I worked with signed off her notes really early one am, you know, on her stable pt. She ended up putting a line thru the pt. resting comfotably, report given line and put error, see code notes.

A new medical resident from a foreign country wrote fat old man instead of obese, elderly man.

[LilgirlRN, ADN, RN]

I took care of a bedbound patient once who was just a litttle bit eccentric. She was perfectly well groomed, no bedsores, had round the clock sitters but wouldn't let anyone touch her feet. The H&P ended with this line..."And she has the longest toenails I've ever seen in my whole life"

[l-andrée]

Absolutely hilarious!

I'm laughing like crazy in here!

[AIS52]

We recently had one of the newer residents diagnose a patient with "Left Middle Lobe Pneumonia!"

I guess anatomy wasn't her strong point!

[sandigapeachlpn]

I was doing my power charting the other night. i was in my robot mode going down the list on my alert charting board. i picked up the name placed it on the 24 hour report and documented 'no problems, sleeping" ( i work noc), then i realized that she had expired on eve shift, i was involved in shipping her out. think i am alittle stressed? i am on vacation this week thank god!

[NurseMonkey]

I work in a facility that has recruited nurses from puerto rico to staff the building. Most of them speak little or no english, and as you can imagine the charting is quite difficult to make sense of. I think the most memorable thing I saw was a pharmacy return sheet where the reason for return of meds simply said "PT DEAD"

[boobaby42]

I have a bad habit of spelling pus or puss, oh heck, which ever, wrong. Everybody gets quite a jolt reading my notes decribing an infection. Pus filled or puss filled. You decide.

[ChristenLPN, LPN]

The funniest thing I ever read was about an annual exam on an elderly woman who had been accompanied by her daughter:

"When I advised the patient that I would be finishing the examination with a rectal exam, I learned that the last fellow to attempt a rectal exam on this patient was hit with a purse and kicked in the groin. Patients daughter was of the opinion that a rectal exam would not be in my best interest and I am in basic agreement with her."

What a cool one he must have been!

[wheelie]

Several years ago when I worked in a CVICU, I recieved a patient from the OR after a CABG. His operative premit stated he had a "coronary artery bypass with cabbage perfusion".

[zapperbapper]

Recieved a pt late in the afternoon after she coded on the floor. The nurses am narative stated "pt found apnic and unresponsive. Will monitor"