Charting Bloopers - page 23
Found in the History and Physical section of a patient's chart who had experienced visual hallucinations while ill: YIKES! https://allnurses.com/bb/eek.gif Angela... Read More
Jan 25, '06Occupation: playing science Specialty: NICU ; Joined: Feb '05; Posts: 3,131; Likes: 1,042seen today:
pt ambulatory c/o existence....
Jan 26, '06Occupation: Dialysis RN Joined: Jan '06; Posts: 6; Likes: 7My personal favorite was written by a very prudish LPN that read "Oral peri-care given" I asked her if the patient enjoyed it and then suggested using a comma next time she documented hygiene.
Jan 26, '06Joined: May '05; Posts: 1,591; Likes: 2,159In Med/Surg Clinical someone had written (the physician, I assume) in a chart: Lomotil, diarrhea PO 25 mg....Is 25 mg of diarrhea a standard medication to give? :chuckle :uhoh21:
Jan 26, '06Occupation: Helping the future of the nursing profession Joined: Jan '06; Posts: 170; Likes: 11I have to pay attention when I chart. If someone is talking, even though i am not consciously hearing, my mind listens to the conversation.
I got called the following day to clarify my charting the evening before because I had charted,
"Patient voiding orange juice."
Jan 26, '06Specialty: 5 year(s) of experience in ICU, telemetry, LTAC ; Joined: Apr '04; Posts: 1,483; Likes: 1,002This week we had a transcribed h & p that said the male patient had a history of a Fundal Plication. Well. I wasn't gonna go looking for his fundus! (Fundoplication was his surgery for GERD)
Jan 27, '06Occupation: Registered Nurse Joined: Oct '05; Posts: 71; Likes: 13From the physician's notes about a first-time pregant, newly admitted OB patient: "Patient is a 26-year old primate".
Jan 27, '06Occupation: Registered Nurse Joined: Oct '05; Posts: 71; Likes: 13Charting on the assessment of an incision of a recent c-section: "infant intact with steri-strips".:chuckle
Jan 27, '06Occupation: taking care of others. Specialty: Med/Surge, Private Duty Peds ; From: GA ; Joined: Jan '06; Posts: 769; Likes: 464how about this one; pt is a quad, vent dependent resp set at 16 and has a foley yet they charted
assisted oob to bath room
assisted to sit in chair for > 1 hr
boy did we get a laugh from that one... but they cont to chart that everyday for 5 months .
Jan 27, '06Occupation: Registered Nurse Joined: Oct '05; Posts: 71; Likes: 13Not exactly a charting blooper, but a pharmacy label error. Label on a tube of hydrocortisone cream: two sprays to each nostril as needed.
Jan 27, '06Occupation: Staff nurse Specialty: Surgical/Telemetry ; Joined: Dec '04; Posts: 469; Likes: 13I used to do QA for a medical transcription company, and have seen a lot of bad charting. One that sticks out is a chief complaint of "infected cooties". (sounded like infectious colitis to me ) This was repeated through the report.
Jan 31, '06Specialty: ortho/neuro/general surgery ; Joined: Jul '05; Posts: 778; Likes: 458This isn't a charting blooper, but funny... (I hope )
We tape record our shift reports and this morning I reported that a trauma patient who had failed a swallow study was on "Aspirin Precautions" :chuckle . I realized it right away but left it on the tape to give them a laugh.
Feb 1, '06Joined: Sep '05; Posts: 8i was assigned in an OB ward and i read a couple of the dx in pts chart written:
NSVD aog 38 wks w/ a healthly bby grl......
then the one written in the other chart was:
NVD aog 36 wks w/ a healthly bby boy......
now im wanderin what is the difference bet. NSVD and NVD, where in fact, both are normal deliveries???!!! whats with the spontaneous and just plainly vaginal delivery???!!! there were about 12 written NVDs in the charts that i have seen, aside from those written in NSVDs...
Feb 1, '06Occupation: Lackey Specialty: 12 year(s) of experience in LTC, Home Care, Medical Offices, Plasma ; Joined: Oct '05; Posts: 29; Likes: 5Quote from sandigapeachlpnThat is so funny. I was working one night, when one of my CNAs who had a higher regard for herself then the rest of us did, came flying out to where I was sitting on my break, and loudly announced that one of my residents needs to be IMPACTED! I straight faced looked at her, told her to gather up every nasty poopy brief she could find, and I would get to work on that promptly!the other night i was working with one of my best cna's. she had been working doubles for a few days, has two small children and can get a little loopy when sleep deprived. gee, can't we all. she is very sharp, intuitive and conscientous. she walked up to me after her last round, dead serious and started talking to me about one of our residents who has quite a distended abdomen due to various, reasons, ascites, etc. .... she questioned me " do you think that the reason ------';s stomach is so big is because she is compacted?" i made trash jokes the rest of the night.