Charting Bloopers - page 6

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   shannonRN
    hilarious thread. keep em coming!!!

    i used to work on a rehab unit and we had an 18 year old with head injuries from a mva. well, he had decorticate posturing. one of the psychiatrists wrote that the patient had "rabbit syndrome!"
  2. by   robinday
    I review charts and come across bloopers quite often. Some of my most recent:

    60 y.o. male with known cirrhosis and portable HTN.

    Family decided on a no code stasis and thought it was time to discuss the femoral.

    Pt. knows the time and space.

    Family history: mother had CA, sister had a sore on her leg.

    Past surgical history: significant for multiple seizures to her ear drum.

    Paul is a 74 y.o. gentleman who is older than his years.

    IV Nafcillin will be started on the basis of quality of staff (sic) coverage and penetration of the CSF.

    She had felt reasonably well over the last week when she had the sudden onset of shortness of breath while driving her coronary artery.

    Arrangements were made to transfer the pain to another hospital where he was to have coronary angiography.

    Isn't this a funny business???????????? )

  3. by   debbyed
    Doctor was charting on a patient with abdominal pain. The patients name was Paulette. "Patient denies pregnancy, denies hysterectomy but states has never had a menses. Plan: Beta HCG and pelvic exam" I would have really liked to be in the room when that physician tried to do a pelvic. You see Paulette was a frequent flyer whose birth name was Paul. He actually looked like a very beautiful woman, but at this point had not had any sex change operations, only hormones.
  4. by   misti_z
    These are really funny!

    In a docs H & P he wrote 'This is a 88yo BM' BM of course for black male.....well......he dictated his note & the finished product read 'This is a 88 year old bowel movement'. Talk about old pile of $hit......just kidding

    Last edit by misti_z on Oct 22, '01
  5. by   stephi57
    At change of shift, 5 RNs, 3 LPNs and the nurse manager huddled over a chart where the pediatrician had just ordered what appeared to be "TL". All that combined nursing knowledge could not decipher what TL could possibly stand for. Finally we admitted total ignorance and called the doctor. Aha!! His rushed handwriting had caused his "TC" for throat culture to look like TL!!!!!
    Moral of the story--beware of abbreviations!
  6. by   NurseDennie
    How about "patient D/C home in wheelchair, voiding excellently."

    I LOVE that one and giggle about it at odd moments (and yes, I do have quite a few odd moments). It conjures a mental picture of the little fire boats welcoming a big ship into harbor - all those water jets spraying into the air.


  7. by   shannonRN
    just last night i was reading a doctor's h&p...well, the last three words were pleasant octagenarian female?!?!?!?! yes the patient was 88 years old, but a generation every ten years? maybe he meant octadecadarian?!!
  8. by   micro
    Oh, my!!!!!!!!!!!! Micro
  9. by   LynniNurse
    We often infuse antibiotics thru a 3way foley that then drains to a bedside drainage bag -- it's called a bladder irigation. Mostly seen with amphotericin B but sometimes even with Vanco. It's really no different than when the dialysis team uses antibiotics to wash thru the patient.
  10. by   LilgirlRN
    Originally posted by janine3&5
    On an ER flow sheet, "16 Fr foley inserted to pt's L nare." ????????
    Foleys are sometimes inserted into a stop a nose bleed
  11. by   Jay-Jay
    Uh, that's true, Lilli, but if you read a little further down the thread you would have found out the patient was a little old lady with SOB....

    I loved the response to the above:

    "Maybe that explains the SOB. Should have just straight cathed that nare!....."
  12. by   Cubby
    While working at our local Psychiatric Hospital many years ago (when nursing was still fun) I had a patient who had lost his shoes a few days prior. Well this particular day he was acting odder than usual so we checked him for an impaction. It was charted like this 'Checked for impaction, shoe found' OH MY!!!
  13. by   fedupnurse
    In a recent H&P: The patient has a history of alcohol abuse and an accident while in a coma.
    Our unit secretary took off a Diprivan order as Tritrate to seduction.
    On an axid order she wrote Acid 150 mg PO BID.
    We had a neurologist called in for a pt. with a head bleed. The doc realized he had met this patient earlier that day when they had a minor MV accident with each other. His 3 page consultation detailed the entire fender bender and what they did afterwards. Maybe 2 lines were about his assessment and plan!
    Another nurse I worked with signed off her notes really early one am, you know, on her stable pt. She ended up putting a line thru the pt. resting comfotably, report given line and put error, see code notes.
    A new medical resident from a foreign country wrote fat old man instead of obese, elderly man.
    Last edit by fedupnurse on May 6, '02