funny charting errors

[hello_nurse_mel]

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:

[al7139, ASN, RN]

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

[justiceRN]

(computerized charting) "neutromember precautions" :w00t:

[~cxJvak]

Oh gosh, mine's not nearly as funny.

Patient was delivered healthy, lady partslly, and full-term by c-section two weeks early.

So what is it?

[Elvish, BSN, DNP, RN, NP]

Oh gosh, mine's not nearly as funny.

Patient was delivered healthy, lady partslly, and full-term by c-section two weeks early.

So what is it?

Both, maybe? I have seen twins born 1 lady partslly and 1 c/s.

Sounds like someone hadn't had their morning java, more likely!

[luna04]

We have computerized med charting. I noticed the other day that when I went to click on PIPPS (newborn pain scale) that the word neck came up.

I had charted that my patient was a pain in the neck!!

[NurseRoRo]

A new grad was working with us on nightshift and wasn't aware that one of our docs is, uh, high maintenance. He gave the nurse some telephone orders and asked that she page him at 4:30am for his wake up call.

Yup. The order went on to read, "Call MD at 4:30am to wake him up."

[bunnylovinggrl]

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."

[bd2rn]

I recently documented that my pt had incurred an injury to her left head.

[turtlesRcool]

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.

[rnprincesstlo]

I was reading my students' documentation during post-conference (a really bad idea!!!). One student wrote "pt ambulating on w/c." I had to leave the room and decided not to read anymore student writing in front of them.

[kakamegamama]

I have not laughed so hard in a long time.....I hurt now.

[silverbat]

I noticed in a chart, written by a student nurse" IV. Infiltrating as ordered. I charged-as s student LPN- dressing site changed. Hummm wonder where I changed it too?? Lol