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."

[JWaldron]

This one I could actually see happening if the doctor was using the balloon to apply pressure to a bleeder. God, I hope that was what was going on. I would hate to hear that there was like 200ml of clear yellow urine returned.

Haven't you heard people say they have to go so bad their eyeballs are turning yellow? This is one way of dealing w/ the situation!

Savvy

[JWaldron]

beachmom said:

My friend's gramdma had a reaction to Demerol. The doctor wrote in large letters:

DEMERAL = CRAZY

Several times I have seen doctors write "foley to gravity"

What other kind is there? Put in a foley to suction?

Well, I DID have a patient come back from the OR w/ an order for foley to intermittent wall suction...and an NGT to bedside gravity drainage!  Maybe the doc's mind and fingers weren't working at the same speed?

Savvy

[RheatherN, ASN, RN, EMT-P]

We all got a good laugh at work after reading a consultation from our ID doctor. She wrote...pt has large amount of ***** drainage... we decided that purulent might look better. (Keep in mind it was a slow day)

i have done that on accident!!! lmao! i was an MA for while b4 nsg school, i wrote this in the chart and then looked at it...OMG! needless to say- that paper went right in the garbage!!!hahahahaha memories!!

-H-RN

[mlolsonny]

BJRN76 said:

We all got a good laugh at work after reading a consultation from our ID doctor. She wrote...pt has large amount of ***** drainage... we decided that purulent might look better. (Keep in mind it was a slow day)

This used to be a running joke, call into another office and ask how to spell "pu**y." No kidding, On a fax to the MD last week: "Laceration to wrist now draining pu**y drainage with redness periwound."

One of our LPNs asked for a list of commonly misspelled words to be posted on the bulletin board (even tho we have spell-check). Purulent (not pu**y) is on there. 

[mlolsonny]

Mistynurse said:

I saw this one on a long-term care note: Patient is pleasantly psychotic. 

Give me pleasantly psychotic ANYDAY over unpleasantly psychotic. Even had a recent discussion with an MD who told me that he used give one of our very pleasantly psychotic LOLs to interns and students for about a half hour, then come and rescue them. She can talk incessantly (and very tangentially) for at least 16 hours a day. :chuckle She's a keeper tho.

[chicookie, BSN, RN]

admitting dx: dental infection related to great toe trauma

[roser13, ASN, RN]

Written on PACU orders:

"NPO until extubated"

Right, 'cause we were planning to stuff a cheeseburger down the ET tube!

[Penelope_Pitstop, BSN, RN]

None of these are errors, per se, but they all made me laugh:

From consultations:

"Pleasant man in no acute distress eating breakfast with a nice beard."

"Patient states the headaches started after the police blew up his house. He did not elaborate on this."

"Patient may look like Santa Claus, but he is very mean and not at all jolly"

"This patient is well known to our service from her frequent hospitilizations. In fact, the last time I saw her, she was standing outside of the ER, smoking a cigarette. She asked me for money, and I declined."

From nurses' notes:

"Progression of care: patient sat in bed." (yes, that was the entire note)

"Patient is being ignorant with me and I'm not even his nurse."

General stupidity...

I wrote a note about a patient's refusal of a nicotine patch. Directly below my note (entitled "Refusal of Nicotine Patch"), two different doctors wrote about how the patient was currently on the patch. The next day, the patient was nauseated and vomited during my shift. I attributed his nausea to PCA Dilaudid. The evening shift nurse and the residents had a different theory. I was told in report the day after that "the nicotine patch is making him sick, so they d/c'd it." I read the notes describing this, and shook my head over the wonders of the Nicotine patch. Gosh, I hope I don't get sick from holding it!

[mybelle3221]

love these!

[sing_anyway]

okay, I am in training for CNA, but here ya go:

during our meeting on the seriousness of charting, what with the great computers we now have,

the administrative boss told a story to get us to stay in line:

The CNA tried to do charting that was for the nurse to do, and on the woman's fall evaluation, was charted for the rest of her life as having had a COMA as a result.

everyone appropriatly ooed and oh no'ed, except poor, dumb me.

I laughed....

I said, can't you see it:

"no, doctor, i do not remember ever having been in a coma!"

~they didn't think it was funny, but I still do!

[HurricaneBreeze]

These aren't charting but still funny...

When the pts are registered, the registrar enters the admitting diagnoses and most of them aren't versed in medical terminology.

We have many admitted with "Periferal Vascular Disease"...last week I had a patient with "Flue".

It always gives me a good chuckle.

[sweetart_1980, RN, CNS]

for a end of life cancer patient who jokingly answered the question posed by the MD u need anything else to help u? she replied a couple shots of vodka would be great! The MD wrote the order 2oz vodka bid prn...way to go doc!