Charting Bloopers

I still crack up when I was transcribing hard copy into a patient's chart. The doctor typed in Herniated Dick into the diagnosis field instead of Herniated Disk. My boss proofed my transcription (I was still a fairly new transcriptionist at the time) against the doctor's hard copy and thanked me for correcting the diagnosis, and couldn't stop laughing while she was talking to me.

Had a diabetic patient with a charted "baloney amputation". I didn't know what to think. Still being a student I was expecting the worst for this poor man.

Mistynurse said:

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

I hope nobody laughs at mine, but they probably will, I recently charted something very similar! patient was pleasantly demented, meaning he was sundowning, his dementia was showing, (sometimes he is A & O X3,), but he was a very happy, cooperative dementia patient!!  I have had numerous dementia patients who were not so pleasant! I guess I will have to think better how to phrase that one, any suggestions?

I found this in a chart..."pt exfoliated himself. Voiding without difficulty. No bladder distention noted."

Umm...I though to exfoliate was when you got rid of the dead skin on your body not to remove a foley.

I gotta remember this one for when it happens at work! LOL

Had a diabetic patient with a charted "baloney amputation". I didn't know what to think. Still being a student I was expecting the worst for this poor man.

OMG! I am SOOO slow - I read this again tonight and finally get it!:trout:

hey guys, could we have about thirty more posts about that foley catheter stopping the nosebleed?

I have a hard time with my new nurse's aides with using correct terminology - instead of saying peri-care or perineum - they often say perinneal care. I don't think we're doing gardening here folks! (and certainly more than just once a year!)

perineal=pertaining to the perineum

perineal=pertaining to the perineum

my charting blooper! :chair: Can't spell - meant to write "perennial", thought something didn't look quite right when I first wrote it. Thanks for the spell check! :chuckle

During a slow moment last week, a co-worker and I were discussing our parents, and I told her about how my mother (who lives with me) can't seem to remember where things go in the kitchen - for instance, I never know where the large mixing bowl is - it could be in the cabinet with pizza pan and cookie sheets, or it could be in the cabinet with the storage bowls. It's always a hunt.

Just at the end of this conversation, Doctor came out and handed me a report to be faxed - which read:

"Patient complains of frequent bowl movements"

I had to take a moment to compose myself and dry the tears. :roll

janfrn said:

Your tale about having to hunt for everyday items after you mom has put them away was too close to home! Hubby never knows where anything goes, even when he's put them away a thousand times. And he doesn't even misplace things consistently... because I usually look for them in the last place I found them and end up hunting anyway.

Frequent bowl movements... and silverware and pots and pans! 

Dunno about your hubby, but my mom's a retired RN - makes me wonder what she did with her med cart!

pt. refused autopsy