Charting Bloopers

oops another...

Cardiologist discussing the need for a "catheterization" with a very HOH older patient. Doc leaves...next thing I know, pt is on the phone with family telling them that he is going for a castration today! And talking so lound half the unit can hear! Wife wants to talk to nurse. Says she's glad to hear it wasn't his heart afterall. OMG

We had two pts with almost exactly the same name (one letter off) .However one was male Leslie . And the other was female Michael.

Poor Leslie varied between BPH and lady partsl irritation .

And michael was status post removal of penile implant one day and candidas the next .

Reading notes from local doctor on a patient from nursing home, who had had a right mastectomy several years earlier..." patient alert x 4, appears well fed, right breast still missing." (like it would grow back like a lizard tail???)

This same doc a few years ago admited a patient to the floor with "pork chop enteritis"...hmmm...

vablueyes said:

Reading notes from local doctor on a patient from nursing home, who had had a right mastectomy several years earlier..." patient alert x 4, appears well fed, right breast still missing." (like it would grow back like a lizard tail???)

I can see it now, "Found: right breast. Please call and identify..." 

RNkat said:

From the physician progress notes on a patient with a glass eye:

"PERRLA"

And then there was the ER doc who charted: "Both breasts equal and reactive to light and accommodation."

ya gotta laugh!

Cubby said:

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!

Ouch! Bet it was hard for the patient to get off on the right foot... Oh well, if the shoe fits...

Postop pt came to our floor with MD order: "Foley to low wall suction".

One of my kids was sort of going nuts post op, he was moving all over the place, seeing stuff ect..I called Dr. for possible restriant orders (to keep his f/c and iscision safe) but a thte time he was calm.

MDs order...."if he goes Ape Sh*t overnight call me"...

IS that a medical definition? Funny yhitng was in the night he was calm but he did have a MASSIVe BM overnight right in the middle of his bed..IS that waht the MD meant? :rotfl:

Pt telemetry alarm going off at desk repeatedly, pt sleeping w/o any distress noted, telemetry turned off at the desk.

This patient was found dead during the 0400 v/s. Needless to say, this stupid nurse lost her liscense and the hospital is involved in a lawsuit.

Recently read H&P where pt accidently took cocaine before hospitalization

Pt with a penile infection:

"Nurse to clean schmegma off pt's member"

Never mind that the pt was A&Ox3, and had 2 good hands.

Seen in my pts chart this evening: Please Toilet Mouth. Thank you.

Had the unit in stitches. What do we do, put toilet water in the mouth. I mean really. And this same md for another pt wrote, Change Prevacid to 30 mg IV. Well, he should have looked at his own orders because the Prevacid was 30 mg IV since the pt was admitted.

And another nurse noted that the MD wrote, if pt dies, don't call me or any resident. Huh?