Charting Bloopers - page 39

Found in the History and Physical section of a patient's chart who had experienced visual hallucinations while ill: YIKES! Angela... Read More

  1. by   Cherybaby
    Quote from diane227
    I love having nursing students on my floor. They are fun and I love teaching and interacting with them. But one of them wrote something funny on a chart today. She wrote in her nursing assessment: "Pt. is concerned that he will not be able to pay his hospital bill. He has been referred for financial counseling and is pleased with the outcome" but there was not one word in her assessment about the physical condition of the patient. I made a copy of her note and I thought about writing an addendum to her note: Pt found in cardiac arrest. Pronounced dead at 11:45. Financial counseling no longer needed.
    Now THAT would be hysterical!!!
  2. by   kkluczynski
    Got an order from the doc the other day it reads " please do not disturb this resident between the hours of 11pm and 8am, these are her normal sleeping times at home. also serve a glass of warm milk at night."

    Really? This resident has a personal alarm, is unsteady at times and confused, but he wants us to leave her alone...hmm.....
  3. by   MassED
    gotta love those dictation errors - that's why MD's, PA's, NP's need to check their transcription when they're done!
  4. by   talaxandra
    From my patient's AM notes: "started 15mg oxycodone to elevate pain."
  5. by   mcpkin
    Had an activity order once- OOB to bed, thought that was funny.
  6. by   chevyv
    I was reading a chart when I came across "pt presents with pu**y drainage". I had to read it more than once before I finally understood what the writer was really saying....
  7. by   teeniebert
    PURULENT! The word is PURULENT! :lol_hitti
  8. by   fiveofpeep
    one grumpy anesthesiologist wrote for a diabetic patient under orders "give her something" ... no scale or type of insulin specified... how classy
  9. by   JayVArn
    "Watch trache like a hawk!!!!" We got a good laugh out of this one. I copied this into the treatment sheet and mentioned it in my note.
  10. by   d'cm
    This patient was being admitted for angiodema and admitting notes on the consent " unable to sign tongue swollen"
  11. by   Spritenurse1210
    Alright, I'm going to put on my big girl panties and admit to this one:

    Patient resting in bed with eyes open WASHING TV!!

    ooops........Needless to say, after a cup of coffee i was able to correct that little gem really quickly!
  12. by   kat von b
    Quote from laurasc
    This happened years ago when I worked on a general surgery floor. A med student had to do an admission physical on a rather voloptuous young woman. On the assessment sheet under "breasts" he wrote "Big and beautiful."

    Needless to say this med student got his posterior cooked by the staff doc.

  13. by   RNstudentforlife
    One day, when I was a nurse in training, I was busy charting and did not realise that everytime I spelled the word assess in our computerised charting, I left the second s left off the end. My charge nurse got a good laugh and told me to take the asse_ out of my charting!