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."

[donmurray]

"coded on the floor" What, no bed? (just kidding!)

steph, I'd go with one "s" in pus, you only need two if you put a "y" on the end, and that can be misinterpreted!

[nrsfear]

this one is the fault of the dictation transcriptionist:

on the H&P' "the pt is a stay at home milk of magnesia"

[DF-LPN]

This was in the H&P:

EOTH

patient states only drank 2 or 3 beers until he met his wife.

was working 3rd, got report from the nurse on a res how ate dinner then aspirated and was having resp distress. went and assessed res came back and read the previous charting which stated:

res ate 25% of meal, started coughing then vomited lg amount of foot.

next entry went like this.

res lungs moist through out with audible wheezing noted, notifed dr of res having vomited lg fool and aspiration.

seems to me that throwing a foot and/or a fool would cause me to aspirate LOL

Dee

[DF-LPN]

had a res come from the va hosp so him and his wife could be together. his wife was a real PITA and never liked to get outta bed and gave everyone a hard time.

the husbands dc summery stated:

this res wishes to be dc'ed to ltc to be with wife, as i have known this couple for a long time i do not recommend this move.

guess he's had several run ins with this lady LOL

[shelley]

We had computer charting where I used to work and I hit submit without reading my entry first. I am an OB nurse. It partially read " O2 remains on FOB at bedside. Report to oncoming sh*t. Forgot a comma before FOB and an "f" in the last word. Now it is on record forever :-I

[OrthoNutter]

How about this one......

pt has not passed urine post-op, MD notified of same. IDC remains insitu, patent and draining well.

And yes, the two sentences flowed one after the other in the chart.

[oplok]

Found in one of Docs order

"Transfer patient to ICU.

Run IV as fast as you can."

he, he, I hope IV is not the nurse.

[Sleepyeyes]

I caught myself in time to correct this lil gem:

"Pt. is a/o X3, cooperative with care, pleasant, SOB."

[Sleepyeyes]

Or this one, from a pt's H&P

"Pt also has heparin B"

[sockov, ADN, ASN, BSN, CNA, LVN]

I work in a busy surgical ICU and a FELLOW (5th year resident), ordered.... Tylenol 650mg IV q4-6hours PRN.

I asked the doc, if he wanted me to titrate to fevers.

my co-workers still laugh at it today. I only wished I saved a copy of the actual order.

[baseline]

Had a patient the other day admitted with Internal Pneumonia........as opposed to external?

[nursechris1]

OMG I am laughing soooo hard, I have tears flowing down my cheeks!!! This was a much needed laugh!!!