Charting Bloopers

[AHarri66]

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."

[SweetieRN]

Charting on the assessment of an incision of a recent c-section: "infant intact with steri-strips".:chuckle

[Lorie P.]

how about this one; pt is a quad, vent dependent resp set at 16 and has a foley yet they charted

rep 20

assisted oob to bath room

assisted to sit in chair for > 1 hr

offered bedpan.

boy did we get a laugh from that one... but they cont to chart that everyday for 5 months .

[SweetieRN]

Not exactly a charting blooper, but a pharmacy label error. Label on a tube of hydrocortisone cream: two sprays to each nostril as needed.

[smilin_gp]

I 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.

[grace90, LPN, LVN]

This isn't a charting blooper, but funny... (I hope:rolleyes: )

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.

[little daredevil]

i 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 lady partsl delivery???!!! there were about 12 written NVDs in the charts that i have seen, aside from those written in NSVDs...

[NurseStace]

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.

That 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!

[perfectbluebuildings, BSN, RN]

I finally have one to add... last night I found an order for a nasal spray written as "one spray to each nose q24h"!!! not one of the best here but I surely got a kick out of it :)

[Marylou1102]

A new student nurse once charted "sitting up in bed watching basketball game on tv. Score 24 to 14"

[HappyJaxRN]

Foleys are sometimes inserted into a nare...to stop a nose bleed :)

WHAT??? Never heard of such a thing. :chuckle I guess where ever this is they don't have nose bleed kits...ya know the thing that looks like a tampon that is inserted into a nare....has a string hanging out....a foley cath in the nare? I have to ask around about that one...hey, whatever works! :chuckle

[HisTreasure, BSN, RN]

An "FYI" sticky in a the treatment MAR: "Per family request, leave window open when in the room giving care. Open when you leave, resident may fall out.":eek:

Wow. I hope I'm not the nurse on duty the day that happens!

Edited to add: I really don't want the resident to fall out, even if I'm not there! LOL!

[McGyverRN]

The H & P read " the patient uses a homo tube..." (home o2).

A nurse's note read " the resident ate two bowels of oatmeal for breakfast"