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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 guess, before he got on the vent ?

A new intern to our CCU once charted attempts to cardiovert a patient in the following manner:

Attempted to convert the patient with 200 jews, unsuccessful. Second attempt to convert the patient with 300 jews unsuccessful. Patient finally converted on the third attempt with 300 jews.

The mental picture of three hundred rabbis surrounding a patient's bed yelling, "Convert, convert!" was too much. We nicknamed him "Call a Code or Call a Rabbi" from that day forward.

Thank you so much for making my day!!! The visual image is too much :)

Patient's family had some questions for the doc so I paged him to call them in the room, but they had already left. Patient herself age 94 answers the phone. The doc then calls me and says, "Do NOT call me back. I don't know what channel Wheel of Fortune's on!"

Sorry, got interrupted before I finished. So next shift charted Patient de-stressed and calling out for doctor. VSS. Dr. H paged to see on rounds."

As a student on OB rotation, I once charted, "Father in. Nursing baby."

My instructor asked me if that was REALLY what I meant to chart?

For a patient in pain, the MA wrote "patient is taking Naproxen, and it works somehow."

Literally word for word what was written in the patient's chart. I think the MA meant to write that it works "sometimes" or something along those lines.

  • Expert
AnthonyD said:
Not so much a blooper, but a very bad order. Nursing free-text order from a PA... "Please remind patient not to drink from his urinal."

We had to keep this one patient's bathroom door locked and monitor him whenever he went to use the toilet!

I have seen under resuscitation status "DNAR (do not attempt resuscitation), would only like to be resuscitated if her life depends on it".

I'm imagining the doctor who discussed this with the patient gave up trying to explain/educate and just stated the patients wishes.

Went to a new pcp office as a patient. I was asked the typical screening questions, "Do you have any STDs, Hep B, Hep C, etc..." I started "no, but I work ini dialysis so I am at a higher risk of exposure." The medical assistant makes her little note on the computer, I didn't think much of of it. I logged into my patient portal later and I see... "Sexually transmitted disease- risk noted- work related".

Has to be the funniest/most mortifying thing I have ever had happen!

I told a MA I was 5 foot two. When I looked in the patient portal he had typed weight 502.. lol I'm fat but not THAT fat. Lol

I work in a nursing home. The other night one of my aids called me over the call and said, "Mr. ____ has a bad rash on his prenatal area and needs some cream." I was laughing so hard and she came out of the room and said, "Are you laughing at me?" I could only shake my head 'yes.' I finally explained to her what prenatal was and told her she meant perineum.

That got me.... I just spewed tea all over my laptop

I was charting my assessment today on a patient when another patient coded, so I had to quickly stop my routine.

As a couple hours go by, I return to finish my assessment finding this:

"The patient is in no distress, vital signs stable, speaking in complete sente"

It made me giggle :)

Resurrecting this thread to share a funny typo we found from a doctor the other day. Patient was in for an injury they got while doing the deed (aka coitus); doc's note said, "injury sustained while engaging in colitis." YIKES. ??

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