Charting Bloopers

We got a kick out of a sliding scale insulin order:

Blood glucose 0-70 1 amp D50 IV

Blood glucose 70-150 Do nothing....

The RN taking care of the pt claimed she could take the rest of the day off, her pt's blood sugar was 110! :)

""I recently saw a "add 20 mEq Kay Ciel to existing IVF" order also. Maybe these docs were trained at the same place."

Almost have to feel some compassion for these poor docs. Anymore they have to spell everything out! They got away with IVF? :chuckle

Once, I saw a resident had written 'p.b.b.b.s' in his progress note (pine-box-by-bedside!!!) I assumed he meant he didn't expect the guy to live much longer.

This is from a chart of an elderly lady from one of our "Higher Learning Centers" who had had a mastectomy, has alzheimers, and is a bit combative:

.....left breast still missing (they grow back??), I was beat off before I could get a good listen (that may be too much information)...

This same doc has also written diagnosis as "Pork Chop enteritis." and has asked patients if they want a pine box or treatment..

I saw this one on a long-term care note: Patient is pleasantly psychotic. :chuckle

I do medicare charting and we frequently write "staff to assist pt with meals, ADL's" and etc.. Anyway I had just finished a 6 week course of Micro HELLLLL ,I went to work one weekend looking over my charting and instead of writing staff I had wrote STAPH on every chart....... :rotfl: :rotfl: . MY whole unit laughed for weeks however the big boss didnt think it was that funny!!!!:rotfl:

Here are some of my favorites:

1. A patient had died and was found in this unfortunate condition by her physician during early morning rounds. The primary nurse charted: "Dr. X walked into room and patient's heart stopped." :chuckle

2. Actual entry of a staff nurse that we were assigned to during clinicals: "Pt. expelled a large green turd." 

3. We coded an elderly man briefly one night a little after 2 o'clock in the morning. The ER doc said the patient was too stiff--rigor had already set in--obviously a lost cause. Unfortunately, the nurse taking care of him had already finished his charting out and had a 6 o'clock entry that matched all the other entries timed from midnight on: "Pt. asleep, resp. eupneic, no s/s distress." 

My own mistakes.......

As a nursing student and doing clinicals in a nursing home I charted a patient was molting ......my instructor asked me if my patient was a bird.

Then one day while working in the ICU it was a particularly hectic day one of my patients died. I charted the death and circumstances on the wrong patient. Fortunately another nurse caught it although it was two days later when she was reading the nurses notes on her patient.

txspadequeen921 said:

I went to work one weekend looking over my charting and instead of writing staff I had wrote STAPH on every chart....... MY whole unit laughed for weeks however the big boss didn't think it was that funny!!

Well it certainly made me laugh out loud!!

AHarri66 said:

Found in the History and Physical section of a patient's chart who had experienced visual hallucinations while ill:

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

YIKES! 

An actual order in a patient's chart who was a very non-compliant diabetic refusing to eat his prescribed diet:

Change diet to 10,000 calorie ADA diet

Back the food truck up to the patient's mouth and dump it in

Even funnier, it was an endocrinologist that wrote it! I guess we all get tested by some patients...

kberl said:

An actual order in a patient's chart who was a very non-compliant diabetic refusing to eat his prescribed diet:

Change diet to 10,000 calorie ADA diet

Back the food truck up to the patient's mouth and dump it in

Even funnier, it was an endocrinologist that wrote it! I guess we all get tested by some patients...

Change in diet order $50.

Endochrinologist order $150.

Mental picture of back food truck up to Patient's mouth and dump it in PRICELESS!!

Elderly gentleman, mid 80-s, explained to the writer that he really hasn't been quite right since the doctor Dx him with "Cancer of the Prosthesis" several years ago...Yes, he had an aritificial limb. Should we call a tree surgeon for this one?