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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."

Featured Replies

I work with some people that just flat out can't spell... One used to continuously write: pt poisoned in bed, pt poisoned in WC etc. She meant positioned, well at least I hope she did...

"Reason for visit: Cabbage"

I had a sick resident who was very somnolent and difficult to arouse even with a firm sternal rub. He also happened to be four days w/o a BM, so I administered a suppository. Even the administration of the suppository failed to wake him up.

So, in my note, I wrote "suppository did not arouse resident"..... yeah, probably could have worded that better....

another one:

a foreign RN I work with documented "resident has pusy drainage from member"

But... she hasn't yet mastered English spelling, and the word "pusy" had an extra 's'....

  • Experts
I had a sick resident who was very somnolent and difficult to arouse even with a firm sternal rub. He also happened to be four days w/o a BM, so I administered a suppository. Even the administration of the suppository failed to wake him up.

So, in my note, I wrote "suppository did not arouse resident"..... yeah, probably could have worded that better....

Haha!

Almost wrote. In bed playing with himself. Caught it. Sigh. Playing quitely.

Progress note: "the wound be healed"

Psyche dr once wrote an order to send pt back to guatemala...lmao

While doing home med rec my finger it the p and the o when typing prn. So it said Media. Fortunately I caught it before it saved!

I'm a psych nurse. Last night when attempting to do a reassessment on a borderline patient, she flipped me off and walked away. So I charted the following:

"When this RN attempted to initiate a conversation for reassessment, the pt displayed the dorsal aspect of the second digit of her right hand in an erect fashion and walked away, refusing to speak." 

bossfrog said:
I'm a psych nurse. Last night when attempting to do a reassessment on a borderline patient, she flipped me off and walked away. So I charted the following:

"When this RN attempted to initiate a conversation for reassessment, the pt displayed the dorsal aspect of the second digit of her right hand in an erect fashion and walked away, refusing to speak." 

That's awesome!

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