tales from the "charts" side

southernbeegirl, BSN, RN · Nov 17, 2008

we had a very strange treatment nurse that charted all kinds of crazy stuff but one thing she charted we STILL laff about 2 yrs later is...

i'll have to paraphrase but she was charting on a bed bound LTC pt...

hip looks like it is disconnected from the leg, patient in severe pain and somebody should really do something.

mama_d, BSN, RN · Nov 17, 2008

My favorite was from the copied LTC chart that accompanied one of my new tele admits years ago (to paraphrase):

"Pt found unresponsive. Started CPR. Pt became responsive and angry that I continued CPR. I stopped compressions b/c the patient hit me after he'd been alert for a few minutes."

The ED staff faxed a copy back to the nursing home with a note following suggesting that staff there keep up their BLS certification a little better.

achot chavi · Nov 17, 2008

My favorite was from the copied LTC chart that accompanied one of my new tele admits years ago (to paraphrase):
"Pt found unresponsive. Started CPR. Pt became responsive and angry that I continued CPR. I stopped compressions b/c the patient hit me after he'd been alert for a few minutes."
The ED staff faxed a copy back to the nursing home with a note following suggesting that staff there keep up their BLS certification a little better.

laughed so hard, fogged up my computer screen:chuckle

nursej22, MSN, RN · Nov 17, 2008

Several years ago my first job as an LPN was in a nursing home (we still called them that twenty years ago). The RNs there made a point of calling themselves "nurses" and the LPNS "practicals". I was reprimanded once for giving a hospice pt an additional percocet (that had an order) without checking with a "nurse" first. :nono:

One evening just before supper an aide fetched me to see one of the residents who wouldn't wake up. I did a fingerstick and by comparing the color to the side of the can (I told you this was a long time ago!) I guessed his sugar to be about 20 mg/dL. :eek: I reported this to the charge "nurse" who was sitting at the nurses' station and said I didn't have any glucagon orders. I walked past her to the med room and got some sugar gel stuff we had, took it to the resident and started smearing it on his gums. He roused quickly and started yelling his usual litany of demands. I returned to the charge to see what other actions I should take. She gave me sort of a blank look. :confused:

Me: "So is there something else we should do so this doesn't happen again?"

CN: "Well, I put a note in his chart."

Me: "Are you going to call the doctor?"

CN: "I don't think that is necessary. He is fine now."

And then she reminded me that I was probably behind on my med pass and walked away. I never looked to see what she charted--I had to get my meds passed.

Thank God I came to my senses and left that place shortly after.

Ruby Vee, BSN · Nov 17, 2008

those are hysterical!

here's one from my own checkered past: "leg is mottled and cyanotic. have notified tree surgeon to come evaluate the limb." (to be fair, it was the 15th hour of a double shift, and i was falling asleep at the time -- after this line, my "charting" continued in a straight line off the edge of the paper!

or, paraphrasing from a former colleague of mine: "have notified the moronic doctor of the rhythm repeatedly and he continues to ignore me. when patient codes, i will tell him i told him so!" and later on "idiot resident ordered lidocaine for ventricular escape rhythm. have not given drug because it's a stupid order. i will tell the abovementioned moron how stupid an order it is when he crawls out of bed." same guy (male nurse approaching retirement and in desparate need of it!) different patient: "patient continutes to complain of chest pain despite ntg drip, iv morphine and rest. he really ought to go to the cath lab right now even if it is a dammed holiday!"

(nurse was invited to take 3 day administrative leave with pay to think about his sins. he enjoyed the admin leave so much he scaled new heights of inappropriate charting on his return.)

ChristineN, BSN, RN · Nov 17, 2008

I work with a nurse that has been an RN for 50 years (longest tenured nurse in the entire hospital). Her charting can be a little entertaining at times. My favorite note of her's was on a pt in a sickle cell pain crisis:

"Pt rang out complaining of pain requesting hot pack. Gave pt hot pack. Hot pack relieved pt's pain, but pt continues to ring out every damn 5 minutes for another hot pack."

oramar · Nov 17, 2008

Once I read a line that a MD had written, "Patient is AAOx3 inspite of her recent brain surgery. However, her mother is so obtuse that one would think that she is the one that had the brain surgery.":uhoh3:

WahooRN08 · Nov 17, 2008

Okay, I love this post: Here are a few from my past.

Working on a Medical floor- one of my fellow LPN's at the time, who was nearing retirement wrote the following narrative pharaphrased:

(Patient background: morbidly obese, diabetic, vascular surgery, LBKA)

No change from initial shift assessment, patient continues to cry due to being fat. However, the patient has eaten 3 cheese burgers and has consumed 5 regular coca-colas, (not to mention the food in the garbage can) despite education and diet teaching to help her reduce the concern about her fatness."

On a patient's assessment:

A little person:

On the MS assessment portion: Patient is a midget

On a person who was not mentally challenged, but the assessing nurse thought different:

"Pt is odd or perhaps retarded."

mondkmondk · Nov 18, 2008

When I started at a "nursing home" as a CNA, this was in early '90's and CNA's were allowed to chart in the nurses' notes, a weekly assessment. One CNA charted this: "Incontinent of bowel and blatter" I was like, who taught her how to spell? Another one I saw of an LPN's was: "B/P stable after fully erect"

Good thread!

Blessings, Michelle

MedicalLPN, LPN · Nov 18, 2008

These are great. I've stumbled across some wonderful nurses notes where I currently work,

"Blood hanging, pt fine."

"Pt looks like he's in pain, I will medicate soon."

"Pt assessed, meds given, vitals okay."

"Pt fell at 1600, vs obtained md notified, pt c/o pain but I think he's alright."

I read these notes in fascination...

pielęgniarka, RN · Nov 19, 2008

Had a new RN that used to chart OU for bilateral. For instance "Res c/o pain in OU lower extremeties" or "drsg changed to OU heel ulcers" LOL used to crack me up! I finally sent her an email that said OU means both EYES.

She was the same one I think that used to chart instead of "purulent drainage" would write "p.u.s.s.y drainage". EEEEWWWWW LOL!