Charting Bloopers

I was a brand new nurse. I had a patient with a very bad burn the entire length of her arm with puss pockets. Unfortunately...I charted...Pt has Pu**y drainage to entire length of arm.......no one noticed but the Dr.

Problem list

Never smoked tobacco

Although I know this was a transcription error, it still made me laugh. "Pt is hard of hearing and wears bilateral hearing autoimmune deficiency syndromes". Also, in another chart, a doctor had transcribed in his notes something to the effect of ... "...Upon digital insertion into the pt's rectum, tonsils appear to be normal in size and structure." WOW, That is some long finger!!

Too funny!!!

How about "contented demented" instead of "pleasantly confused" !! I've heard that in a handoff report a few times!

not a charting problem, but this was the text of an x-ray report: "views of the left elbow were taken which show a third finger pip dorsal dislocation with slight ulnar angulation."

I wonder exactly how many fingers he had in his elbow? 

"catheter exit site positive for gram positive cock site"

I am a home health nurse, I called Med Records to find out what one of my patients had been admitted to the hospital for....the non-medical person who answered the phone informed me that my patient had been admitted for hyperchlamydia. Stunned by this as my patient was not really someone who would have this nor would they have a HYPER version, I asked her to spell it for me....she spelled H-Y-P-E-R-C-A-L-C-E-M-I-A. Laughing I said ok thanks but that is hypercalcemia, much different from hyperchlamydia....

In nursing school, one of my fellow students wrote that a patient had a pulse grade of 2 for his posterior tib and pedal pulses. Too bad the patient had both of his legs amputated many years before he was on the unit...whoops. And here's your sign. 

FC RN BSN said:

In nursing school, one of my fellow students wrote that a patient had a pulse grade of 2 for his posterior tib and pedal pulses. Too bad the patient had both of his legs amputated many years before he was on the unit...whoops. And here's your sign. 

I've seen charting errors like this one done many times, and not by students but experienced RN's....scary, huh?

crissrn27 said:

Hi, new user, just found this website, it's great! Anyway, had to share this story, not a chart blooper, but a huge blooper anyway. Years ago I was an MDS nurse in a SNF and the state was making rounds with one of our (masters prepared!) floor nurses on his med rounds. The nurse noticed the pt needed honey thicked liquids, so he insist (to the inspector with him) that he must go to dietary to get honey to thicken the liqiud! needless to say we did not pass inspection that day

ha-ha ?