Published
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:
Here are a handful of chart bloopers from my office. I'm sure I'll be adding more to this list as I come from an office where English is not the native language for most of the employees, including our doctor:
"Patient is also here for RT Foot pain occurs for 1 week. Pain began after little incident took place at her home country. She was in public place where cloud with many people. She was standing with the cloud and one big heavy lady walked by and stepped on her RT Foot."
Treatment: Prescribed "Ben Gay prn"
"She is here for for needful and further suggestion"
Under Treatment: "Morbid (severe) obesity due to excess calories. Notes: Loose weight."
(instead of lose weight, lol)
Patient scheduled for "gluteus mateus" injury
"She has continuous aching pain and is unable to bend her knee backwards."
On our MAR, the drop down menu has many reasons to choose from to explain why a mediation was not administered. Unfortunately, the order is problematic with "patient expired" right before "patient refused." Yup, evening nurse got a good laugh at my documentation for why our quite-alive patient didn't get her dulcolax that morning. There have also been several times when I've chosen "combative" when I'm scrolling to "cooperative," but I don't think I've clicked save for the wrong one...yet.
al7139, ASN, RN
618 Posts
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