Best MD note - page 4

There may or may not be a thread like this but I couldn't resist sharing. This weekend I was digging through my patient's chart trying to learn more about his history when I came across a note by the... Read More

  1. by   TopsDrop
    My favorite one just happened recently actually. It started off something along the lines of "this patient's has to many problems to even begin to explain in this H&P, Her history is very long and complex so please refer to previous notes and good luck"

    The entire H&P was hilarious I was cracking up the entire time.

    Best part was the plan.

    "check for signs of osteomyelitis and then I have no idea from there at this time"
  2. by   beachmom
    This was a night shift nurse's note in a LTC facility. "No pulse, no BP. Will keep comfortable."

    She left the next morning, saying nothing about it to the day shift. Day shift CNA, of course, found pt. dead. The nurse was let go. I always wondered what the official time of death was, and if the facility told the family about this.
  3. by   BostonFNP
    Quote from beachmom
    This was a night shift nurse's note in a LTC facility. "No pulse, no BP. Will keep comfortable."

    She left the next morning, saying nothing about it to the day shift. Day shift CNA, of course, found pt. dead. The nurse was let go. I always wondered what the official time of death was, and if the facility told the family about this.
    Was this pt CMO and the nurse was documenting to keep comfortable and not take pulse and BP anymore?
  4. by   BostonFNP
    My collaborating doc is very (pleasantly) unpolished, man of few words, and direct (and strangely enough patients love him). I was doing a 3 month follow up and came across one of his comments in the problem list under obesity: "she is still fat, doubt it will change, keep trying.".
  5. by   marydc
    My favorite was a note made by the psychiatrist after a patient had intentionally kicked me in the stomach. "Patient is well aware of right from wrong. In my opinion needs a therapeutic trip to jail."
  6. by   chare
    Quote from cbs1980
    One of our pediatricians .charted child bitten by dog 10 days ago mom states dog is fine, nothing was ever charted about how the child was doing.
    Quote from GitanoRN
    Hey some people have their priorities in that order... LOL... Aloha~
    I realize that this is an old post, however this is actually important information. If the dog is fine 10 days after after the incident then it is not rabid. If the child has not started the rabies series then he or she will not have to do so.

    Having undergone the rabies series several years ago, I can assure you that it is not fun; especially the human rabies immune globulin (HRIG).
  7. by   al7139
    Order for one cigarette q day. He had a very heavy accent and was misinterpreted by the scribe
  8. by   serenidad2004
    Dictated by my favorite nephrologist in a progress note about a very complicated patient "it appears we are still up sh*t creek without a paddle" I had to read it 3x before I believed it.
  9. by   dariah
    I once came across this gem in the chart of a PCOS patient...
    "Pt has hair like a man"
  10. by   michigansapphire
    After a detailed description of a difficult central line insertion: "Pt has earned a chocolate donut."
  11. by   nursedeb42
    I was receiving admission orders over the phone in the middle of the night and the very sleepy doctor was spouting out his usual questions "What labs do I need to know about? Has the pt got back from MRI? Has she had pain meds? Did I give you activity orders? Have you had any birthday cake?" I said "No, but my birthday is in 2 weeks so you should probably include that." "Okay, add that to the orders. Thank you, good night."
  12. by   Leonca
    These are hilarious! Kind of makes me wish the vets I've worked with weren't so bare-bones on the notes they were required to keep.
  13. by   TeriNICUrn
    Quote from Zapazol
    I still recall the doctor, a psychiatrist, who wrote an order "Give drug STAT on Thursday."
    Lol that's hilarious.

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