Funniest or worst PDN notes.

[KATRN78]

In my year of PDN I have read some terrible notes!

Why do nurses write things like "patient playing with ball on floor and watching tv. nurse read book to patient" or "patient played with nurses cell phone, laughing." ?

oh lets not forget nurse charting "skin dry, pink and intact" on a child with a G-tube. G-tube doesn't = intact skin.

What strange notes have you seen?

[KATRN78]

My favorite (but not funny): "...client be chillin' in the bed". Client had passed on. Don't think they meant that the way it ended up, but a terrible pun.

Might have been the same person that charted "pt an ma r watching computer"

[Dazglue, ADN, BSN, MSN, RN]

insead of "passy muir" nurse put a "u" where the "a" belongs......hehe she got teased about that one for a long time!!

Actually done that this week...twice. The first was in the ER and of course it was PLASTERED over the giant Cerner board for all staff to see and we all got a good chuckle out of that.

[chrisrn24]

insead of "passy muir" nurse put a "u" where the "a" belongs......hehe she got teased about that one for a long time!!

Hahahahahaha too good!

[smartnurse1982]

I always found it strange that i went through 5 years of working as a nurse(both as an lpn and Rn)

and i had never hear that used before,except on Allnurses. I have incorporated restimg with eyes closed into my charting.

[missLPN2RN]

Of course you will know if your pt is sleeping if you know what their baseline VS are! My peds pts wear pulse-ox probes when sleeping and spot check while awake... as ordered. When they are awake HR, R, & O2 Sats are higher than when sleeping.

Ex. HR -140 R-36 SaO2-99% while awake

HR -102 R-30 SaO2-98% while napping x1hr

[KATRN78]

Here is a new one another nurse read to me at the office "pt has a lot of boogers and junk today. Cleaned nose with qtips and saline"

[systoly]

playing with a ball or reading may address developmental skills

"boogers" is ok to use, but junk should be replaced with "snot" for a more accurate description

[nursel56]

I don't think I would use the word "booger". Junk could mean tracheal secretions or the sound of a coughing through lots of congestion in the lungs. I think most people think "nasal" when they think "snot".

[SDALPN]

Snot and junk seem very inappropriate to me. I would use "secretions"or describe the drainage from the nose. Maybe something like "copious, thin, clear secretions observed in nose"....or whatever fits the situation.

[Not_A_Hat_Person, RN]

One of my clients has a G/J-Tube. When I need to access it, I tell my client "I need to take a look at Mr. Tube." I once charted "Flushed Mr. Tube with 30 cc water, no difficulty."

[smartnurse1982]

My agency seems to give Esl nurses a pass with the spelling and grammar.

For example:

Many write "Reposition for comfort". Thats it. They dont say what side.

Many write only one word,like "suction" with a period,nothing else.

As if one word constitutes a sentence.

95% of these nurses are educated here in the Usa.

[SDALPN]

My agency seems to give Esl nurses a pass with the spelling and grammar.

For example:

Many write "Reposition for comfort". Thats it. They dont say what side.

Many write only one word,like "suction" with a period,nothing else.

As if one word constitutes a sentence.

95% of these nurses are educated here in the Usa.

Its not a requirement to document which side the pt is turned to for most cases. I agree that just writing suction is ridiculous. But they will hurt themselves and possibly the agency with that.

Just the other day I saw "4.0 CFS Shiley cuffless trach". CFS means cuffless. Clearly the nurse has no idea what CFS stands for. But the nurse left out any documentation on care for the inner cannula or the fact that it was the correct size inner cannula in the trach.