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Discussion

Charting Bloopers

Have you seen any charting bloopers?

Found in the History and Physical section of a patient's chart who had experienced visual hallucinations while ill:

Quote
"Patient vehemently denies any auditory, tactile, or old factory hallucinations."

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Another medical chart bloopers."Pt.complaining of headache.Tylenol given as ordered.Checked back with patient one hour later and head gone."

Here are a few:

Medical orders and advice:

May have lollipops orally.

She is to refrain from sexual intercourse until I see her in the office.

For his impotence we will discontinue the meds and let his wife handle him.

MD order: May shower with nurse

She can begin to use the lawn mower, but no lady partsl entrance.

This isn't a blooper but we have a resident who has doctors orders for "Pats on the back twice a day".

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My husband had foot/ankle surgery done and a nurse friend shared a charting goof on his chart with me.

"Change rt. foot and ankle dressing q 12 hours.... rt. AKA on December 12...."

Just one question. How the heck do you change a foot and ankle dressing on NO foot or ankle?!

I guess his foot and ankle just spontaneously regenerated.

sharpeimom said:

Just one question. How the heck do you change a foot and ankle dressing on NO foot or ankle?!

I guess his foot and ankle just spontaneously regenerated.

Ooops!

Just one question. How the heck do you change a foot and ankle dressing on NO foot or ankle?!

I guess the same way a bilateral BKA patient has pedal pulses, heels elevated, bilateral knee high scds and teds on and the correct color socks indicating fall risk on their feet. One nurse I used to work with chatted all those...

CrazierThanYou said:
This isn't a blooper but we have a resident who has doctors orders for "Pats on the back twice a day".

I guess he needs burping for an indigestion dx! 

"Pt family pureed foot and fed it to him and he ate it all"

The handwriting on it was very neat, it was clearly f-o-o-t not f-o-o-d.

"He urinates from his urethra and also drinks from his suprapubic catheter."

Hmm, somebody didn't correct his consult after dictation...

I saw a nurse chart "wound has ***** drainage" in a nurses note. lol. I have a dirty mind, I know.

^ Same as above. Instead of "pus-like" drainage.....

One new nurse charted and notified MD "pt has 3 episode of fuel-smelling loose BM" LOL haha she might have pooped gasoline lmao! Instead of foul-smelling..haha

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