Jun 12, 200025 yr 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."
Mar 2, 200620 yr In my class my prof went over some charting blooper some where:"both patients breast were equally and symetrically reactive to light and accomodation" instead of "...eyes were equally..." another was "the patient was raped in the usual fashion" instead of reading "...patient was draped...".I thought that was kinda funny (aswell as the rest of my class)
Mar 2, 200620 yr I would attribute this type of chart bloopers to medical transcriptionists who are either in a terrible hurry, or don't speak English very well ...
Mar 2, 200620 yr Order given: "Fortified foods at all meals and HS"Order written by charge nurse: "Four to five foods at all meals and HS"Now THAT one took me a while to figure out!
Mar 2, 200620 yr was supposed to read Shift Summary...somehow the f was dropped! Must have been a long day ...
Mar 3, 200620 yr Hey there everyone- Reading this forum made me and my co-workers crack up. I also had one of my own to add. One of our graduate nurse's accidentally put a note in a pt.'s chart that said, "Jeff is Kool-Aid man," speaking about the RN, who kept saying to him "Oh, yeah." OOPS- He was really embarassed when the RN found that in the chart.Keep the laughs coming!!!
Mar 3, 200620 yr Hello again!!! Forgot another funny story.My mom, who is also an RN, recently created a thong depends!!! (apparently she had way too little to do that night!!!) She and another nurse even made a poster and got someone else to model it over her scrubs and took pictures of their "trial product" from depends. It's still in their break room!!!!
Mar 16, 200620 yr When I first Graduated from school I worked in a small hospital, that would frequently put noncontagious pts such as kidney stones or chronic pain, on the post-partum unit, when the hospital was full. Found in a Male Kidney stone patient's progress note written by his Primary Physician... "fundus firm" .....geeeez where was HE feelin'?
Mar 17, 200620 yr My sister tells me of interesting stories...she works in ICU ( as I am yet only nursing student...) here goes.Reading her patient's chart, this popped up:Healthy-appearing, decrepit 69 year old male, mentally alert but forgetful. and how do you like ths charmer:Patient was released to outpatient department without dressing.
Mar 20, 200620 yr The other day I was caring for a Hispanic baby whose father spoke English and mother did not. Nurse wrote in the chart:"Mother is Spanish speaking, but father speaks good English."Maybe he could teach the nurse a thing or two?
Mar 21, 200620 yr I still laugh at this one...( a patient with restless leg syndrome) a student wrote "sleeps with jerks" ha ha ha!!!!! also saw charted on notes one time years ago... " HWB ( hot water bottle) turned on low." ....
Mar 27, 200620 yr had a nurse who signed off an order for IV Flonase. I went up to him with the Flonase bottle and asked how to inject and if one puff or two was sufficient. He got really mad! The order was for IV Furosemide. BIG DIFFERENCE. OH YEAH, he was our charge nurse, Scary!
Found in the History and Physical section of a patient's chart who had experienced visual hallucinations while ill: