Inappropriate Charting

[Oceanpacific]

I try to be careful what I write in documentation about patients. My guiding principle is to "chart as if the patient were going to read it." Upon occasion, I have read documentation written by someone who is angry or disgusted or is a terrible speller or has no clue.

At one job, a CNA was told that charting "Patient had a BM" was not descriptive enough. Later that day the CNA charted on another patient, " Had a BM at 2 o'clock. It was brown, about a foot long and as big around as a broomstick." Sometimes you get just what you ask for. Do you have any charting gems?

[Rose_Queen, BSN, MSN, RN]

Not so much inappropriate charting as a "What were they thinking?" scheduled surgery:

Peritoneal craniotomy. Supposed to be parietal craniotomy. Obviously, our surgical schedulers don't take medical terminology. Or, we were going to do a crani through a very interesting approach. Or, the patient had his/her head up his you know what.

But for other examples, here's a thread that's been going for the last 15 years.

For some reason, the link isn't working for me. If you search for charting bloopers, it'll come up.

[Oceanpacific]

Thanks, that thread looks like a gold mine.

[traumaRUs, MSN, APRN]

Nope, good link to good thread. Thanks.