Charting Bloopers

Nurses Humor

Updated:   Published

Have you seen any charting bloopers?

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."

pt: jane doe, A/O/A, smoker since she could hold a cigg, lungs sound like ****.

hey, you gotta call 'em like you see (hear?) 'em!

Dr in to examine wound. Odor present. Dr. Smith present.

I'm not sayin'......but I'm sayin'.

Specializes in Trauma Surgery, Nursing Management.
brandiashley said:
here's an error I made once after a very bad day, thankfully only on the report sheet for the next shift (and DON, CEO,CFO, ect) and not in the actual charting:

pt: jane doe, A/O/A, smoker since she could hold a cigg, lungs sound like ****.

this is what I normally think in my head but gets automatically translated into proper term (crackles throughout bilat lung fields) w/o any conscious thought, but that day, there was a major break down of communication between my brain and my hand. oops.

Oh how funny! Sometimes I wish I could write things like that in my charts without getting in trouble!

Specializes in Trauma Surgery, Nursing Management.

A patient was being stubborn about getting up from the bed and walking 5xqd 1st day post-op, and the note that was written by the nurse was this:

"Pt states at home that she is usually sedimentary and doesn't need to walk today."

Hmm....the patient is usually rocky??

Specializes in mental health + aged care.

At handover today, the staff member going off shift said "[pt's name] complained of cockroach". The then thought about it for a moment and said, "oh wait, it could be earache"

As a CNA, reading some of these posts I'm glad we're not allowed to note in the pt's chart. That way I can't be blamed for confusing CBI with hooking IV to F/C! That's a pretty embarrassing error, not to mention dangerous if it were actually done.

Specializes in Acute mental health/ Eating disorders.

On a psych ward I once read notes of a collegue stating;

Patient challanged me to game of chess, I accepted and beat him. Patient stated this was first time he'd ever been beat. PLAN: encourage patient to play more chess as part of rehab.

Couldn't stop laughing at this

Although not written a collegue of mine has often described a patient as 'Mad as a box of frogs' durign handover.... God I love psychiatry.

Specializes in Coronary Rehab Unit.

Not a blooper (as it's obviously deliberate....), but we have an RN on my floor who puts smiley faces in her assessments..... LOL

Specializes in Ortho, Case Management, blabla.

"the patient developed severe, 10/10, epigastric abdominal pain, which persists today. This was associated with nausea and vomiting of undigested food, which he states he ingested approximately 2 days later. "

ewww 

Specializes in Medical.

Oh, november17 - I hope that's a charting blooper rather than reportage, but I can't imagine what it should have been...

Specializes in Ortho, Case Management, blabla.
Oh, november17 - I hope that's a charting blooper rather than reportage, but I can't imagine what it should have been...

It was supposed to say "two days before"

Specializes in Medical.

That's considerably less distressing :)

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