Charting Bloopers

Dr in to examine wound. Odor present. Dr. Smith present.

I'm not sayin'......but I'm sayin'.

brandiashley said:

here's an error I made once after a very bad day, thankfully only on the report sheet for the next shift (and DON, CEO,CFO, ect) and not in the actual charting:

pt: jane doe, A/O/A, smoker since she could hold a cigg, lungs sound like ****.

this is what I normally think in my head but gets automatically translated into proper term (crackles throughout bilat lung fields) w/o any conscious thought, but that day, there was a major break down of communication between my brain and my hand. oops.

Oh how funny! Sometimes I wish I could write things like that in my charts without getting in trouble!

A patient was being stubborn about getting up from the bed and walking 5xqd 1st day post-op, and the note that was written by the nurse was this:

"Pt states at home that she is usually sedimentary and doesn't need to walk today."

Hmm....the patient is usually rocky??

At handover today, the staff member going off shift said "[pt's name] complained of cockroach". The then thought about it for a moment and said, "oh wait, it could be earache"

As a CNA, reading some of these posts I'm glad we're not allowed to note in the pt's chart. That way I can't be blamed for confusing CBI with hooking IV to F/C! That's a pretty embarrassing error, not to mention dangerous if it were actually done.

On a psych ward I once read notes of a collegue stating;

Patient challanged me to game of chess, I accepted and beat him. Patient stated this was first time he'd ever been beat. PLAN: encourage patient to play more chess as part of rehab.

Couldn't stop laughing at this

Although not written a collegue of mine has often described a patient as 'Mad as a box of frogs' durign handover.... God I love psychiatry.

Not a blooper (as it's obviously deliberate....), but we have an RN on my floor who puts smiley faces in her assessments..... LOL

"the patient developed severe, 10/10, epigastric abdominal pain, which persists today. This was associated with nausea and vomiting of undigested food, which he states he ingested approximately 2 days later. "

ewww 

Oh, november17 - I hope that's a charting blooper rather than reportage, but I can't imagine what it should have been...

Oh, november17 - I hope that's a charting blooper rather than reportage, but I can't imagine what it should have been...

It was supposed to say "two days before"

That's considerably less distressing :)

Just posting so I can follow this thread. It's a nice change from the usual stuff.