Charting Bloopers

I read in a chart "Pt complaining of headache. Tylenol given as ordered. Checked back with pt one hour later and head gone!"

Didn't know Tylenol could take off your head! Yikes!

One of my co-workers said she saw a chart that said "Pt had large bowel movement ambulating around floor!"

Amanda :)

the other night i was working with one of my best cna's. she had been working doubles for a few days, has two small children and can get a little loopy when sleep deprived. gee, can't we all. she is very sharp, intuitive and conscientous. she walked up to me after her last round, dead serious and started talking to me about one of our residents who has quite a distended abdomen due to various, reasons, ascites, etc. .... she questioned me " do you think that the reason ------';s stomach is so big is because she is compacted?" i made trash jokes the rest of the night.

One time a MDand not a resident wrote this order;

"Bath pt od"

While doing clinicals as a student, I found this error while reviewing a pts chart:

0130 Pt very restless and crying all night, contacted MD who gave VO for a shot that would put her to sleep.

0245 Pt lying on back in bed. Looks very peaceful after being put to sleep.

I'm not kidding!! 

This one I found on a LTC note by a nurse:

Pt is pleasantly psychotic.

In our ER patients who do not have a physician are assigned one for admission. We have a rotating call list that we call "Dr. None".

We had a brand new intern who went in to examine a Spanish speaking diabetic with no Dr. She kept asking him who his Dr. was and I finally told her, "Dr. None".

Next thing I know, she is calling the operator to have Dr. NUNN paged!

ok, this is veterinary (I'm not a nurse yet) the chart for a diabetic cat who was transferred from another hospital said "gave karo syrup, sub Q) The tech's actually tried putting the syrup in a syringe to see if it would squeeze through!! hahaha

During Halloween at our childrens hospital, each unit decorates pumpkins using that units theme. We also let the kids decorate them and take them to their rooms. After awhile they start to rot. I had a MD come in and write an order to bath patient stat!

Transcribed dictation is a constant source of hilarity for me.. on the OB floor: "Gross fecal movement noted" (the doc said "fetal").. or on lady partsl exam: "small bloody shell" (that would be "show" - I haven't seen one hatch yet..  )