I review charts. Here are a few things that caught my eye over the last few weeks. Houston, we have a charting problem...or a transcription problem. What are some of your favorites that you have seen?
agreeing discontinues artery toe would keep her on discontinuing
Add Tamiflu 75 milligram twice a day pending influence that test result
56 y/o male patient who was found on the flow.
The patient has presented with a recurrent vomiting for last 3 days and recurrent scissors.
Patient feels much better and headache has notoriously decreased.
I think it is better to do a formal chest CT noncontrast to be sure there is no a tumor producing the obstruction considering his high wrist.
in to the emergency room complaining shortness of breath on mild exertion. Also at rest everything started this morning when he was having breakfast he start experiencing problems catching his hair .
Specializes in LTC, assisted living, med-surg, psych.
One of the weird things I do when I'm bored is peruse my online medical record to see test results, as well as what my doctors are saying about me. I can't read all their notes, but the account of my recent hospital stay was pretty informative. What's funny is this line: "Patient found significant benefit to male you've (milieu) activities with her peers on the unit."
Thank you all for these hilarious posts! Made me laugh and put me in a good mood just before I head in to help all the new Christmas babies be born tonight! Merry Christmas!
Most of the errors that I see are the result of copy/pasting or template use. I am a big fan of pedal pulses being 2+ on a BKA patient. It's also always impressive when a physician documents a head to toe on a patient who wasn't in the room when the physician rounded. Gee, I guess they just have went all the way down to MRI to see the patient.
Copy/pasted nurses assessments make me roll my eyes also. The patients "goal" for the shift is still to be "NPO after midnight for lap chole tomorrow morning" at 09:00 the day of surgery. I also see PCT's documenting urine output for dialysis patients who are AOx4 and able to tell me that they are anuric and haven't voided in months.
I've seen quite a few humorous charting done by voice to text programs. Some of them are obviously issues with the voice recognition, some are probably influenced by accents, and some are obvious English as a second language issues. Some of my favorite with the voice recognition software is the last names that might be common words or similar to common words. For example, a certain chocolate company would be two words (female pronouns) instead of a single name.
My husband used to have use a transcription service for his voicemails. He had some hilarious ones from his old business partner, who was Indian and had a very thick accent. He'd always crack up reading the transcriptions and try to decipher what they were SUPPOSED to be before listening to the VM.
I went to my cardiologist recently. He grabbed my chart, read for a minute. Tossed it to the side. Said "What the hell? I can't even read this crap! I swear I never documented any of this nonsense! Take off your shirt."
I almost make this one error on a daily basis. In our computerized charting for care plans, I have to type what happened on my shift. Sometimes SHIFT gets typo-ed to SH*T . Hopefully I have caught and corrected the errors I have made.
I do this too! I hope I've never typo-ed that one...
. Hopefully I have caught and corrected the errors I have made.
anon456, BSN, RN
3 Articles; 1,144 Posts
I had a kid who was admitted for "accidental indigestion"