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

Nurses General Nursing

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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 ICU, Float RN , Quality & PI.

"dubble breastectominy"

I thought this nurse can not be serious or stable. Does she realize what she just wrote!!! omg!:lol2:

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Specializes in Medical.
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.

I for some reason googled the phrase "acute coffee" - and got over 1,000 hits! Sure, some of them were about an acute coffee crisis and most of the rest were research reports about acute coffee consumption/ingestion, with a few random sites I didn't click through ("Trafficking feels acute coffee for easily to two hours") and no clincial presentations of acute coffee...

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Specializes in Medical.
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!
I once worked with a nurse who said she was 5'13" because she didn't like the idea of being over 6'
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Specializes in OR Hearts 10.

I work in surgery and our admission history is filled out by the RN's in same day surgery. Daily thing are mispekked, one of my favorites is DNC, I know thats the way it sounds..... but come on

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Specializes in ortho, hospice volunteer, psych,.

after the contracter doing roofing repairs on our metal roof cut his hand, he showed it to me and i drove him to the er. they sutured his hand and we returned home. he asked me a question about his discharge orders and i read his sheet. the er doc had written, "... with very gross bleeding." not "gross amount of ..." or something similar. i gave my best explanation of whay "gross" meant and that it didn't mean disgusting.

kathy

shar pei mom:paw::paw:

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.
I work in surgery and our admission history is filled out by the RN's in same day surgery. Daily thing are mispekked

Heheh.

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Specializes in Utilization Management.

Recently, a patient came in after being injured while standing under an awning at work. The next day, I was reviewing the dictation, and it had been written as "Patient injured while standing under a can of beer at work."

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Specializes in LTC, Subacute Rehab.

Our unit sec. has come up with a few lately:

Pshyc consult

Excess phuylgm

Hx cabbage x4 :yeah:

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Specializes in med-surg, psych, ER, school nurse-CRNP.
One of my favorites for a male with a PEG was "give via Fallopian tube."

Holy Toledo. Now, THAT I would have wanted to see, carried out, that is.

Heck, I'd have paid money to see that one!

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Specializes in med-surg, psych, ER, school nurse-CRNP.
Our unit sec. has come up with a few lately:

Pshyc consult

Excess phuylgm

Hx cabbage x4 :yeah:

oh

my

Lord.

As a cardiac NP, that last one kills me. God love her.

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Ha! P***y is my favorite too.

I am also one that is bothered by the misspelling of "HIPPA", it's "HIPAA" people. Sadly, I wasn't surprised when I saw it spelled wrong in the preceptorship handbook of program. I'm picky about spelling (& penmanship), probably why my charting (still paper at some hospitals here) takes so long - don't want to misspell words nor have the charting look messy because of crossing out misspellings. My theory on doctor's penmanship = they write so sloppy so that no one can notice if they misspell :)

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Specializes in OR Hearts 10.
I work in surgery and our admission history is filled out by the RN's in same day surgery. Daily thing are mispekked, one of my favorites is DNC, I know thats the way it sounds..... but come on

Dang, quick reply doesn't let you edit, LOL

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