Charting Bloopers

I caught myself charting this the other day:

"No Lasix given for I>O due to inaccurate output record on previous ****."

It was suppose to say "shift."

Patient satting 95% on 50% "vinny" mask.

Patient with history of "cabbage" in '07.

Heparin and TEDs s/c.

In home health, I once charted "pt discharged home from hospital with assistance of "souse"...wearing "thigh high RED hose" (typos on computer charting)

It sounded like those two had quite a night ahead of them!

*wine

I may or may not have written "Pt states hx of pancreatitits, thinks is having relapse" on an intake form, but I cannot confirm or deny any such occurrence.

Keeping a list of admitting diagnoses lately.....

Inflammatory BAVEL disease

Hyperbilirubin Anemia

...can't remember the rest...should have writtent them down!

Heres my favorite:

Med transcriptionist charting a transfer summary listed a med as :"Cigarette 180mg daily" (it was supposed to be "Cardizem 180mg daily").

Amy

w/ o2 cannula attached to uro bag...

Just the other night, in an H&P on a hip fx:

"Patient is allergic to Percocet, Tylenol #3, and Darvocet. All those medications caused goofy."

A- that's not an allergy, that's a side effect

B- if those meds "caused goofy"- what caused Mickey and Pluto?

"Fall: The differential diagnosis is mechanical vs. syncope. Since patient is not unconcious, syncope unlikely."

Sure, doc, cause no one could ever pass out and fall, then come to in the 8 hours between when he fell and when you dictated this?

To his credit, english wasn't this doc's first language.

my fav is

"pt pleasantly confused"

and the time one of our male nurses charted that he examined mr smiths lady parts

I wonder if "pleasantly confused" is a legitimate description. I have also seen this on multiple LTC charts, i thought it was funny at first but then I began to wonder...

By the way everyone, keep the hilarity coming! I laughed so hard on some of these I think I might have strained something.

I wonder if "pleasantly confused" is a legitimate description. I have also seen this on multiple LTC charts, i thought it was funny at first but then I began to wonder...

By the way everyone, keep the hilarity coming! I laughed so hard on some of these I think I might have strained something.

Sorry to get serious--it's so unlike me--but you raise a fair question. I've used that expression, at times, but is it legit? Some patients are surely more "pleasantly" confused to the staff--cute and funny, as opposed to confused and agitated or confused and combative. But it does at least appear that some confused patients are in a happier alternate reality than others. But it's worth remembering that pleasantly confused can turn to fearful rather quickly. I'm thinking of a lady who thought her television was a window and was enjoying watching all of the horses running in the yard, but then was alarmed by a close-up of Audie Murphy and thought he was a peeping-tom.

Still, she was a happy little 90 y.o. girl again in a few minutes. I guess if you have to be confused, it's better to be happy.

From one of my friends "Diagnosis: Sick" That's all that was written... Sick with what?