Now, if you saw this on a chart, what would YOU think?

[AngelfireRN, MSN, RN, APRN]

Came up to do a consult, and was going over the PMH for this patient, and am sitting here yet, wondering WTH?

Now, I may be being picky, and grammar is my pet peeve (Southern voice notwithstanding), so please don't flame me. The sheer amount was what got me.

Allergies:

Bactrium, Dioxicycline, Augmenatin, Arythriomycin

PMH:

Fibriomylagia, hitatal hernia, hystorectumy, rotocuff sx, carptal tunnel sx, plantar fashistisis.

Took me a sec to realize that a NURSE actually filled this out. I thought a family member did it.

Yes, I know that no one's perfect, but this just floored me for some reason. I know you can look at these and figure out what the girl was getting at, but, sheesh!

What are the worst clinkers you've ever seen on a chart, supposedly written by a medical professional?

And go ahead and flame me if you want to, it's freezing here!

[Emergency RN]

"plantar fashistisis" ??? is that shistosomiasis of the foot? lol...

sorry, couldn't resist

for my money, i'm more upset with people who don't know the more common differences between you're versus your; or could have, misquoted as could of.

[KansasFNP]

Ouch....

[traumaRUs, MSN, APRN]

As long as I can read it or decipher it, I just ask the pt.

[leslie :-D]

that's pretty shabby, lol...

leslie

[sharpeimom]

you aren't nuts or overly picky. my first career was as an editor and proofreader. i edit absolutely everything! not deliberately; it just happens. i tell myself that i could have a worse habit -- like chewing tobacco or humming nonstop just under my breath like my aunt does.

if i had read the chart, my reaction would have been what yours was.:eek::eek:

kathy

shar pei mom:paw::paw:

[VivaRN]

Could've caused an error - that arythriomycin referring to erythromycin or azithromycin? Especially when you throw messy handwriting into the mix.

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

I applaud your concern over this. I have a very rare condition (look up watermelon stomach, and you'll be the only one on your floor who knows what it is!). I went for an EGD and was presented with a permit for tonsilectomy and adenoidectomy because the MD had written "TA". I suggested they change the permit to read "thermal ablation." Any form of unclear communication is a setup for trouble.

Especially watch out for communication triangles, where messages are going around through 3 people. They never work.

[Kooky Korky, BSN, RN]

I think you'd be doing a favor for the writer and everyone who has to read what he or she writes if you will let this be known to whoever supervises this person and see if some remedial work might help. If this is a nurse or if it's a transcriptionist, either way, it's really very unprofessional, very second rate. Could conceivably be dangerous. At the least, it's embarrassing and annoying.

Make it known and ask that the person be given some spelling help. Could be there are other problems that should be addressed, too, with that person.

[~Mi Vida Loca~RN, ASN, RN]

I read an entry from a Dr. that said the Pt. had episodes of acute coffee :| I am assuming he meant coughing since it was a respiratory pt.

[spider11]

Some of our Docs use the computerized dictation. It's downright pitiful. If any of those documents ever go to court....Lord help us. lol

[SuesquatchRN, BSN, RN]

One of my favorites for a male with a PEG was "give via Fallopian tube."