funny charting errors

I havent seen this one, but had heard it from one of my professors...a nurse was assessing the LOC of a patient, and wrote easily aroused. Just those few words can be taken many different ways!

I saw this once on a chart under "social history" for a new admission

"patient lives with wife but works part time in a whorehouse"

(the resident was learning English. he meant "warehouse")

Written by a Doc as an order: "Elevate balls between legs on 2 towels"

I'm not kidding... We had to ask him the next day if he thought we would be confused as to which balls to elevate, or where to elevate them. :smackingf

First, I'll tell on an EM resident: "Return to ED for signs of infection...redness, fever, pu$$y drainage..." (This was an arm laceration!)

Then, I have to tell on myself: "Pt c/o right wrist pain after admitting to 'overuse' during weekend..." (He had chopped wood, using axe/hacksaw/etc!)

written on a chart in an OB/Gyn's office:

f/u ck up

was supposed to be: follow up check up (nurse who wrote it was notified)

doc had to be notified of error since she also documented on page. :rotfl: :rotfl: :rotfl:

That was too funny. Isn't it funny how some of our abbreviations are sometimes wacked up.

Thought I would share a few things documented in the patients' records.....

Patient has chest pain if she lies on her left side for over a year.

On the second day the knee was better and on the third day it had completely disappeared.

She has no rigors or shaking chills, but husband states she was hot in bed last night.

The patient has been depressed ever since she began seeing me in 1989.

Discharge status: Alive without permission

The patient has no past histories of suicide.

Healthy appearing decrepit 69 year old male, mentally alert but confused.

He expired on the floor uneventfully.

Patient has left his white blood cells at another hospital.

She slipped on the ice and apparently her legs went separate directions in Chicago.

The patient had waffles for breakfast and anorexia for lunch.

Between me and you, we ought to be able to get this lady pregnant.

The patient was in unusual good health until his airplane ran out of gas and crashed,

She is numb from the toes down.

While in the ER she was examined, x-rated and sent home.

Occassional, constant, infrequent headaches.

Patient was alert and unresponsive.

When she fainted her eyes rolled around the room.

MD at bedside attempting to urinate x3-unsuccessful.

Complete blood bath given. Patient tolerated well.

Since she can't get pregnant with her husband, I thought you would like to work her up.

Coming from Detroit, this man has no children.

The list is endless. We were always taught in school.....if it isn't documented, you didn't do it. Wouldn't our instructors be pleased now?

We had a neurology resident write in a progress note:

"Unable to assess pt d/t pt in a cage."

The pt was in a Veil bed.

I work in a PACU. Had an add-on appendectomy last night that was coming from another town near by... the nurse wrote a verbal order that read....

"Notify Dr. ****** when pt hits the floor."

HITS THE FLOOR??? I CERTAINLY HOPE NOT!!!! LOL

I work in an ER where our Docs frequently write on the chart pelvic exam with RN assist when we need to do a pelvic exam. One of our Docs took it a step further by writing "Pelvic exam with nurse in lithotomy." I was very embarrassed the next day when my supervisor called me at home laghing because I had signed off on the order.

Not really a chart error, but funny:

Jesus tested + for ghonerrhea.

(pt. is Hispanic & RN that charted it is Catholic....said she felt evil having to write that. :innerconf :roll

Not really a chart error, but funny:

Jesus tested + for ghonerrhea.

(pt. is Hispanic & RN that charted it is Catholic....said she felt evil having to write that. :innerconf :roll

I really love this one. I am a Christian, and I laughed SO hard. I go to a Christian college and just shared this with some of my friends and they laughed to.

Heres a good one:

We have a doc whose accent is difficult to understand. The dictation staff have a really hard time transcribing his notes because of this.

For a discharge summary med list the medical records person wrote (I am not kidding!)

Cigarette 0.125mg daily.

What it really was supposed to be was:

Digoxin 0.125mg daily.

I was actually alerted to this by the receiving nurse at the nursing home the pt was being transferred to!

Talk about learning a lesson! Now I ALWAYS read over the discharge orders to make sure there are no mistakes like this before I fax!

Amy