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."

[grace90, LPN, LVN]

Pt in ED for a dog bite; MD wrote

"Patient was bitten by his own doctor"

Maybe the doctor bit him because he got tired of the pt coming in for ridiculous complaints.

[RN4NICU, LPN, LVN]

I charted this one after a difficult IV start in the NICU:

"Infant tolerated procedure h*ll"

Should have been "well" but probably reflects what the baby thought of it.

[walkingrock, ADN]

When I had to do all narrative charting for the assessment in NICU, I kept finding myself accidently writing:

infant in open CRIPT

instead of open crib....

[cota2k]

How about having a bamboo bag available for conscious sedation?

[DoubleblessedRN, ADN, RN, EMT-B, EMT-P]

I once picked up a pt from LTC who pulled out and damaged her PEG tube. The narrative area on the transfer sheet stated, "PEG tube busted. Please replace."

I also once saw eurosepsis and hyperpotassemia written in a chart.

[cardiacRN2006, ADN, RN]

I also once saw eurosepsis and hyperpotassemia written in a chart.

I saw hyperpotassemia also written in a chart. I pointed it out and laughed at it. BUT, unfortunately for me, it's a real word.

[JosieKitty]

One busy day in the ED, a doc told me to set up for a pelvic exam in room 10.

Imagine my suprise (and the patient's!) when I wheeled a pelvic cart into the room and HE apparently knew what it was because HE said "Oh, I don't think so!" I had to inform the doc that the male patient refused the procedure...

[bjlyst]

i read recently in the nurses notes; pt. alert and oriented, "may he rest in peace."

[UM Review RN, ASN, RN]

Found these H&Ps recently:

Patient has quite a large stomach. In fact, he actually looks quite a bit like a Buddha.

Patient then went into asystole and was coded. Obviously, since patient is now an inpatient, code was successful.

[SeeK]

i once wrote in a paranoid schizo's chart that had a BS on the lower side...."offered patient a snake"....of course you know i meant snack and even after i drew my line through it you could tell what it said and i was teased for awhile....lol

[SeeK]

oooohhh and my husband is an ICU nurse, he said one dr. wrote in the patients chart...."if patient codes, be sure to SLOW code him, IF he makes it through the night, get chest xray"...my husband called him and said "i dont think you should of wrote this in the chart....the doctor first couldnt understand why but he must of consulted with peers because he was on the floor 15 min later and re-wrote the order...thankfully for his sake his had been the only order on that page so he could just throw it away

[JWaldron]

Just last night at work I checked an H&P - the admitting Dx was CVA, but the history stated that the patient tripped and fell at home, hit his head, had a subdural hematoma, a subarachnoid hemorrhage, a non-displace occipital fx...and NO mention of a CVA anywhere in the history. TBI or CHI alone would have been good enough to get this guy into RHB, where I work - the doc didn't have to find some Dx that wasn't substantiated by the hx! The surgical history, Item 2. was "Awake, alert and oriented repaired in 2003." Maybe a lobotomy?? It must have worked, whatever it was, because this poor guy has no retention of anything, and can't seem to remember much of the past either.

Savvy