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."

[Thedreamer]

Im an LPN student. This was a morning I was doing clinical on a med/surg floor.

Report from the nurse included all the usual, meds, dx, ect. At the end she simple said while walking away, "Oh and he REALLY likes baths!"

Well after I had taken care of everything I figured I would help the CNA out and change his linens and give him a bath. He was able to ambulate quite well but requested I bed bath him. I did section by section till I got to his groin area. I then asked him if he would like to wash himself so that I didn't invade his privacy. He looked at me quite bright eyed and said, "Fella, that'll be the 4th person to play with me in years, so you go on right ahead, Ill just watch." 

So I charted my nursing note at the very end, "Bed bath given and thoroughly enjoyed" The RN got a kick outta that 

Always fun to make light of an awkward situation hehe.

[SweetieRN]

A new charting blooper written by a pediatrician that was attending the delivery of a preterm infant: "infant delivered via c-section with apgars of 8 and 9 with no signs of being dressed".

[Rizpah]

I work in a nursing home. The other night one of my aids called me over the call and said, "Mr. ____ has a bad rash on his prenatal area and needs some cream." I was laughing so hard and she came out of the room and said, "Are you laughing at me?" I could only shake my head 'yes.' I finally explained to her what prenatal was and told her she meant perineum.

I have a hard time with my new nurse's aides with using correct terminology - instead of saying peri-care or perineum - they often say perinneal care. I don't think we're doing gardening here folks! (and certainly more than just once a year!)

[grace90, LPN, LVN]

I once had a patient that I reported off as being on 'Lasix precautions' instead of 'Latex precautions'! 

[santhony44, MSN, RN, NP]

nightnurse7 said:

Pts with amputations having equal pulses to affected extremities. Can you have phantom pulses like you have phantom pain? 

I had a patient once who had q4 hour neuro checks. He'd been on the floor for several shifts already.

Got my little penlight, checked his eyes. Hmm, something odd about that left eye- I didn't think I saw the pupil change. Checked it again. The third time I checked it, the patient looked up at me and said "Glass eye!"

Apparently did it not only look just like his other eye, up until I checked it, the pupil reacted to light, too. 

Amazing things they can do with glass eyes!

[santhony44, MSN, RN, NP]

grace90 said:

I once had a patient that I reported off as being on 'Lasix precautions' instead of 'Latex precautions'!

I annoyed a doctor once when I said that a patient had a "Nissan" fundoplication rather than a "Nissen." Yes, I knew the difference, somehow I just opened my mouth and the wrong thing came out.

He walked away muttering something about little trucks......

[Crux1024]

I have just read all 42 pages and wow! i have never laughed harder! Its great to see that this thread has been going for 6 years! I hope I have some to add soon

[nursemike, ASN, RN]

grace90 said:

I once had a patient that I reported off as being on 'Lasix precautions' instead of 'Latex precautions'!

Two urinals at the bedside?

[grace90, LPN, LVN]

Two urinals at the bedside?

Yup, there ya go! And pad the bed up good. That's Lasix precautions for ya!

I think I actually saw an order once on a urology patient on Lasix for "two urinals at the beside, expect a lot of urine output"

[Rizpah]

Internal message from RN supervisor to charge nurses: ****'s wife is concerned about an increase in confusion (likely related to recent increase in Duragesic patch). Until he develops a tolerance to the increased patch dose, please try Regular Tylenol if the PRN needed to decrease confusion. (Unless pain is severe, then use the stronger PRN). Thank you.

Now I know, what she's saying is to try PRN Tylenol instead of the PRN PO narcs he has available. But another staff member asked me, "since when do we use Tylenol for confusion?" 

[carlarn, BSN, RN]

I was working in the ER at the time and was writing discharge instructions. The patient had been seen and treated by the plastic surgeon. I was standing at the counter writing and apparently listening to my colleagues talking because I caught myself AFTER I wrote for the patient to "Follow up with Dr. X's wife in his office". I had to write the instructions over, thankfully before they reached the patient.

Several of my ER colleagues would chart "patiently easily aroused". Hmm what did they do for the patient?

One chart notation for a surgical consult--the requesting physician made the comment that the surgeon should do "whatever sh*t he felt like doing". I was appalled and had to ask several other people if that was in fact what was written.

[grace90, LPN, LVN]

Rizpah said:

"since when do we use tylenol for confusion?"

Wouldn't it be cool if we could?