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Discussion

Charting Bloopers

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."

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...and another more recent one. I once without thinking asked a double amputee how tall he was. Then as an effort to redeem myself proceeded to follow up with. "and how much do you weigh?" --Needless to say, I couldn't wait to get out of there.

I work with an older nurse who charts like she talks. A man was on go litely and she charted "on toilet-go litely working."

I work with a new LPN who constantly gives Tylenol for our elderly patients, which is a good thing that she cares about their pain.... However.....

She charts this...

10am --- ASAP 650mg P.O given for c/o "10" headache

Instead of APAP 650mg.....

I tease her constantly of the speedy-ness of her pain management!!!!!

Everytime I see it in the chart.... I chuckle....

I work with an older nurse who charts like she talks. A man was on go litely and she charted "on toilet-go litely working."

In my Nursing class, our instructor introduced us to Go-Litely by saying "it does anything but make you go lightly. It makes your pt go heavily, go oftely, and you go quickly when your patient rings your new friend, the call light."

I had the unfortunate experience of having to take Go-Litely several years ago, and I agreed with that statement completely. And I to this day wonder if the name Go-Litely was someones idea of a joke.:rotfl:

I think they should rename go-lytely to go ever so heavily !

Actually, that last one might be legit--I think they do that sometimes for very severe epistaxis, puts compression on the bleeder, I think.

yes- it's used for packing off a posterior bleed.

Pt came up from ER with admitting dx of "Sinkable episode"

Scary thought ....This was written by an M.D.???

Yes it was written by an MD.

I was working in the ED last week when I had to call David ******* into triage who presented to the ED with lady partsl bleeding. We were very busy that day and at least an hour had gone by with his name and condition on the list before I had a chance to call his turn. I guess he found the restroom and the tampon machine because he was gone before we got to him.

Now before anyone gets upset with me because of "conditions" or choices that he may have made... I think he signed HIS name and his wife's condition to the board.... silly mistake.... and gave us a needed laugh on a VERY busy day.

Sally

I must be really tired, can't stop giggling. Maybe he was thinking about putting a back potato in the tail pipe!

Pt came up from ER with admitting dx of "Sinkable episode"

Maybe they thought that he had drowned. able to sink

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