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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:

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

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MD actually wrote the following order:

Connect IV to F/C

I guess he had recycling on his mind!

Originally posted by outbackannie:

MD actually wrote the following order:

Connect IV to F/C

I guess he had recycling on his mind!

Recently when I was working in a hospital I was assigned to a pt. that I was told had IV fluids infusing into his bladder via a 3-way catheter. On futher exam of the chart the MD had ordered an antibotic infusion due to a severe bladder infection. We continued the infusing during the night, but still wonder how successful the treatment was since the foley was connected to a BSD bag. The treatment was stopped the next day.

I must confess that I, too, described thick, white drainage as "***** ." Luckily, it was while I was in nursing school when we all spent time agonizing over our notes and first wrote them on scrap paper. I did figure it out before it went on the record but we had a great time laughing about it at post conference and it still makes me chuckle whenever I write "prurulent."

When I was a new grad I had a patient with a staph infection in her right eye and cellulitis of the surrounding tissue. It was nasty !! Lots of pus and drainage.

I charted (sometime between 3-5am) right eye- red, swollen P,U,S,S,Y.

The next night I caught it. Funny though, the girl in the next room who had just had a baby 2 days prior, (I don't remember her diagnosis) called me in the room and asked if I would look "down there" to see why she started hurting so bad. When I looked, she must have had some kind of abcess because the labia majora on one side was red and swollen

On an ER flow sheet, "16 Fr foley inserted to pt's L nare." ????????

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

Unfortunately, it was written on a little old lady with SOB!

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oops! Never mind, then. frown.gif

Could explain the SOB. ?  Maybe they should have just straight cathed that nare? ?

Originally posted by janine3&5:

On an ER flow sheet, "16 Fr foley inserted to pt's L nare." ????????

foley's are great for stopping nosebleeds, the balloon works miracles

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Originally posted by ratchit:

Could explain the SOB. ? Maybe they should have just straight cathed that nare? ?

?

How about "sleeping quietly in open crib. Diapers clean and dry" on a 22 yo new MOM! Whoops.

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