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

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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!

Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.

That's a future CRNA.

yikes....lol!

My favorite gripe is the social worker who consistently spells niece "neice". I do wish we had higher spelling and grammar standards in nursing, but since my abilities are declining rapidly I'd be the first one up for correction.

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

two days ago my husband complained about pain in his fallopian tube, the right one to be specific... I was laughing so hard I had tears rolling down my face. I knew he meant Eustachian tube, but c'mon, the man has a PhD in Psych n brain developm.:rolleyes:

He did correct himself very fast and told me I could not tell this story to my sister, who would tease him relentlessly... I immediately called her!!:jester:

Oh you guys are making me laugh! Thanks :)

Specializes in Med Surg/Tele/ER.

Wheew! That is pretty bad! I know spelling is my weak point so I always look up anything I am in doubt about.

Specializes in Health Information Management.

As a former journalist married to a copy editor, I'm alternating between laughing to the point of muscle spasms and shaking my head over the potential dangers of such blunders. BTW, the case of "coffee" was priceless. That's a Freudian slip if I've ever heard one; the doctor must have been craving a caffeine infusion! :lol2::lol2:

Oh I have found many gems in my chart auditing- including my favorites "pt has typing diabetes", "pts mother deceased from all summers disease" and "pt allergic to statins as they cause polio".

Obviously transcription errors (I hope) but the MD clearly isn't reading what he/she dictated.

Specializes in Hospice/Mental Health/LTC/Home Health.

At my nursing school if you spelled something wrong, your whole answer was wrong.

Specializes in PICU/Pedi.

I was going through an O.B. patient's chart last week and I had to ask another student to confirm what I saw written. Listed as her height was 4'12"!! I said, "Isn't that 5', or am I just sleep-deprived?" The student agreed that it was. We laughed about it, and so did our clinical instructor when we showed her the next day. AND it was written by a doctor!

My favorite is the doctor who described the pt's wound drainage as "pu__y" instead of purulent.

Specializes in Medicine, Surgery, Critical Care.

My favorite is Levofed... ugh! If you are giving a med that means life or death know how to spell it!

A person favorite in chart review is description of an infected wound bed ...puss*. Purulent people.... It has purulent drainage.

Specializes in Medicine, Surgery, Critical Care.
My favorite is the doctor who described the pt's wound drainage as "pu__y" instead of purulent.

Hahaha I didn't read your thread first great minds :)

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