Charting Bloopers

Found on a Progress Note:

55 yr m admitted with signs of chest pain. Pleasant to speak with. Family aware of status. Patient states that chest pain occured while his wife was on him having dinner.

Cardiac protocol taken.

*** found on drs orders same patient****

D/c viagra.

We had such a good time with this one..

Zoe

One of my classmates had to correct her note after she accidentily wrote "pt ate 50% of lung"

Wouldn't that be a site to see!!! :)

These are wonderful but make me wonder what oddball things I've written! Oh well maybe someone will get a laugh out of me!

Sarah

One of my personal favorites: "Pt unconscious and complaining of leg pain". How'd he do that?

But then, I've written weird things too, especially when someone interupts me midthought an hour after my shift has ended.

Joan

Once I accidentally charted "pedal pulses present" and "pedal pushes palpable" in haste. The following shift another nurse who is quite notorious for copying rather than performing assessments charted the exact same thing. I found it quite amusing to see in her notes.

I don't suppose this is an error but it was definitely different:

on the results from a UA

traces of talcum powder

The secretaries taking messages, more than once wrote:

Worried about Billy Rubin.

Yeah, He's a scary dude...

From a radiology order form: "CXR r/o Aplat's pneumonia"

Should have read: "CXR AP/LAT r/o pneumonia"....we only figured this out after trying to look up "Aplat's pneumonia" in several radiology texts and reference manuals.

".....Problems stemming from being an illegitimate child, due to the social MORAYS of the time..........." They really used to bite!

Here's one I saw today.

"Minor is 18 years old"

This was the probation depts way of letting me know a change occured.....Thanx,need to know!

Had a Doc at LTC who hated regulations and was a constant battle to get him to write dx for each med he ordered. After several requests he wrote dx for MOM order: can't sh**. Had to leave it on the chart....I'm sure surveyors saw it, but never said a word.

I review medical records all day and have come across some really wierd ones.

"from both flebitis" (thrombophlebitis?)

"very close veins" (varicose?)

"patient is matching his eyes and his nose" (I's & O's?)

" no evidence of libido on lower extremities" (livido?)

"paralyzed with the neck team" (Anectine?)

"ptosis given @ 2 mu for induction of labor" (Pitocin?)

But I guess my all time favorite is "two lane hospital" (Tulane)