Charting Bloopers

Nurses Humor

Updated:   Published

Have you seen any charting bloopers?

Found in the History and Physical section of a patient's chart who had experienced visual hallucinations while ill:

Quote
"Patient vehemently denies any auditory, tactile, or old factory hallucinations."
Specializes in Critical Care.

I saw a neuro surgeon's notes once that said, among other things, that the pt's LOC had decreased and he needed to go to the OR for a ventric.

I can't remember exactly how he wrote it, but it came across that the pt needed to go to the OR because the neurosurgeon's LOC was decreased.

~faith,

Timothy.

0 Votes
Specializes in CCRN-MICU_SICU_CCU.

This happened about 2 or 3 am. Not A charting blooper but a verbal slip up.

We had a patient in with a drug overdose, her pressures were falling. Phoned the doctor who told us to give her some tylenol and make an appointment in 1 month. The nurse that called the doctor was really new and just hung up. She called him back a few moments later after consulting others and got an appropriate order. when this was told to the doctor the next am he also got a good laugh.

0 Votes
Specializes in OB, M/S, HH, Medical Imaging RN.

1. The patient has refused an autopsy.

2. The patient has no previous history of suicide.

3. She has no rigors or chills but husband states she was very hot in bed last night.

4. Pt.c/o chest pain if she lies on her left side for over a year.

5. On the second post op day the knee was better, on the third day it disappeared.

6. The pt.is tearful and cries constantly. She also appears to be depressed.

7. The pt has been depressed since she began seeing me in 1993.

8. Discharge Status: Alive

9. Healthy appearing decrepit 69 y/o man, mentally alert but forgetful.

10. Pt.had waffles for breakfast and anorexia for lunch.

11. She complains she is numb from her toes down.

12. In ER, was examined, x-rated and sent home.

13. The skin is moist and dry.

14. Occasional but constant infrequent headaches.

15. Pt is alert but unresponsive.

16. Rectal examination revealed a normal sized thyroid.

17. Pt stated that she had been constipated for most of her life until she got a divorce.

18. I saw your patient today, who is still under our car for physical therapy.

19. Both breasts are equal and reactive.

20. Exam of genitalia reveals that he is circus sized.

21. The lab test indicated abnormal lover function.

22. Skin: somewhat pale but present

23. The pelvic exam will be done later on the floor.

24. Patient has two teenage children but no other abnormalities.

0 Votes

:uhoh3: :uhoh3: :chuckle :uhoh3: :uhoh3: no more needs to be said.

suebird :p

0 Votes
16. Rectal examination revealed a normal sized thyroid.

Whoa......:eek:

1 Votes

thats a looong finger

1 Votes

26. Bleeding started in the rectal area and continued all the way to Los Angeles.

27. I’m not constipated; I can breathe just fine.

28. Patient was becoming more demented with urinary frequency.

29. Patient walks six blocks now. The doctor told him it may take a year to come back.

30. She stated that she had been constipated for life, until she got a divorce.

these are funny Dutch!

0 Votes
Specializes in PeriOp, ICU, PICU, NICU.

These are too funny! Thanks for sharing :)

0 Votes

"The patient is in a persistant vegeterian state"

0 Votes
I read in a chart "Pt complaining of headache. Tylenol given as ordered. Checked back with pt one hour later and head gone!"

Didn't know Tylenol could take off your head! Yikes!

Speaking of the healing wonders of Tylenol...I work nights in the ER, and it can get hairy, even at 0300 in the am. We also use paper charting for everything, even D/C instructions. Imagine my surprise one early am when reading my own handwriting to the parents of a febrile child "alternate tylenol and motrin every 3 years". Whoa! talk about extended release. Luckily, they had a sense of humor when i explained my error.

0 Votes
Specializes in Transplant, homecare, hospice.

What a hoot these bloopers would be in court....Can you imagine being on the stand trying to explain that one...how embaressing. :imbar

0 Votes
Specializes in Med/Surg, ICU, educator.
zambezi said:

Originally Posted by panda_181

One of my co-workers said she saw a chart that said "Pt had large bowel movement ambulating around floor!"

Amanda ?

I have seen this happen--more than once. It is not pretty. 

you know, we had to recarpet the floors on our unit just for this reason...

1 Votes
+ Add a Comment