Charting Bloopers

I have to confess *raises hand* I'm a new grad, I removed a Pt's staples from his head, then charted on it. Instead of writing dehiscence I wrote: "7 Staples removed from left side of scalp. No signs infection, No signs evisceration. Patient tolerated well."

Oops. At least it was true and his brain didn't spill out!

Terre said:

A new intern to our CCU once charted attempts to cardiovert a patient in the following manner:

Attempted to convert the patient with 200 jews, unsuccessful. Second attempt to convert the patient with 300 jews unsuccessful. Patient finally converted on the third attempt with 300 jews.

The mental picture of three hundred rabbis surrounding a patient's bed yelling, "Convert, convert!" was too much. We nicknamed him "Call a Code or Call a Rabbi" from that day forward.

Now that I've taken ACLS this seems a lot more funny to me now! 

"Resident was reported to be quite lethargic @ noc."

BJLynn said:

"Resident was reported to be quite lethargic @ noc."

Oh my, wasn't that the night it was dark out?

theofficegirl said:

This is the absolute BEST I've ever heard! I literally cried from laughing so hard. Oy VEY! I realize it's a few years old (from 2001!), but I've called a few friends to share... this is priceless!

"Rythym abnormal, regularly irregular" Well, which is it, Doc?

Other than the misspelling of rhythm, there's nothing wrong with this. We do see pts who have a regular pattern of irregular beats

brainynurse said:

We recently had a new resident come and pronounce a pt deceased.

He charted in the progress note: pt appears stated age of 104, cause of death unknown.:balloons:

Although it's obvious that OLD AGE was the cause, I believe it is not an official cause of death anymore. (Blame the insurance companies and people who write all the medical codes) The docs have to come up with something that was treatable as the cause of death.

one day I am taking care of a guy with hf... the edema in his arms and legs was about 4+. IV lasix, the whole 9 yards.... noncompliant heroin addict with sores all over his arms. spent the last 10 years on the streets after serving a 20 prison sentence. all of this is obviously in his chart. this guy is in desperate need of help. I am looking over different consults and find one from a social worker who interviews the pt and gives her recommendation for housing. based on his current health conditions and financial (or lack of) situation he "might" be eligible for housing assistance. one catch though, if he has been incarcerated or had any felony convictions he would not be eligible... I thought, did she not read his hx? to add further insult she told the patient all of this info....

do people actually do their jobs or is it an illusion?

how about...instill 2 and 1/2 gtts OD q4h?

The nursing home was in the middle of survey at the time and the doc was in no way impressed with the state. He wrote the order on purpose!

Pts with amputations having equal pulses to affected extremities. Can you have phantom pulses like you have phantom pain? 

One of our CV surgeons was charting and dictating at an alcove I was charting. He said - either I was having a really bad day or the transcriptioinist was having even a worse day - the typed notes indicated that "Mrs.S" has an ELECTRON MICROSCOPE on her sternum. Dr. B trying to imagine the size of such microscope being on her sternum totally dissolved this man to tears!! It was hilarious!!!!

Im an LPN student. This was a morning I was doing clinical on a med/surg floor.

Report from the nurse included all the usual, meds, dx, ect. At the end she simple said while walking away, "Oh and he REALLY likes baths!"

Well after I had taken care of everything I figured I would help the CNA out and change his linens and give him a bath. He was able to ambulate quite well but requested I bed bath him. I did section by section till I got to his groin area. I then asked him if he would like to wash himself so that I didn't invade his privacy. He looked at me quite bright eyed and said, "Fella, that'll be the 4th person to play with me in years, so you go on right ahead, Ill just watch." 

So I charted my nursing note at the very end, "Bed bath given and thoroughly enjoyed" The RN got a kick outta that 

Always fun to make light of an awkward situation hehe.