tales from the "charts" side

Xbox Live Addict · Nov 19, 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

Our reception and donor floor techs come up with some doozies in spelling (reception makes out the ID card which lists the donor's allergies).

My favorites? "Lower Tabs" (Lortab), "Asaparin" "Sephilaxin" (cephalexin) (these folks generally lack any kind of medical training.)

rnlately · Nov 19, 2008

Our reception and donor floor techs come up with some doozies in spelling (reception makes out the ID card which lists the donor's allergies).
My favorites? "Lower Tabs" (Lortab), "Asaparin" "Sephilaxin" (cephalexin) (these folks generally lack any kind of medical training.)

It makes your brain hurt when you have to decipher these spellings. It wouldn't hurt if they had a drug book/medical dictionary nearby.

southernbeegirl, BSN, RN · Nov 19, 2008

I have one on myself. I had a patient that her daughter wanted her to have a coke every afternoon. in my defense, it had been a long day! lol, i charted "pt's daughter wants her to have a cock every afternoon".

sad thing is, i wasnt the one that found it and the DON wanted to know if i care planned it!

achot chavi · Nov 19, 2008

Thats OK, I once had 2 patients who required a lot of my time- one died and i spent some more time consoling the family, the other one burnt herself with a cup of tea her son brought to her.

It was the end of a double and i charted - "Son came to bury patient with tea" but I caught it and crossed it out.

mama_d, BSN, RN · Nov 19, 2008

I had a patient once who had these awful diabetic ulcers on both legs, from the knees down. He refused amputation despite the recommendation of multiple docs. His son swore that the alcohol baths he gave to his father's legs every day would eventually cure them, despite the fact that his care had led to wounds so bad that you could see the tendons.

Doctor's paraphrased charting: "Wounds not amenable to healing even though I've discussed it with them repeatedly...patient and son upset b/c I talked to the wounds and want a different doctor. Explained to them that talking to the wounds will promote healing better than what they've been doing and unless they agree to amputation, no other doctor is going to want to deal with them. Advised son to pour rubbing alcohol in his own wounds to see how it feels since he is so concerned with our lack of pain management for his father. Unfortunately risk management does not believe that this case is enough to get patient away from son's care, but will follow up. Told case manager not to bother b/c the son is going to kill his father soon anyway."

And I thought that WE got frustrated with this kind of people...

rnlately · Nov 19, 2008

Ok, that's hilarious and it shouldn't be.

CapeCodMermaid, RN · Nov 19, 2008

I worked with a wonderful nurse at one facility. Her clinical skills were great...her spelling however was not.

I was doing chart reviews and saw that in many of the charts she had written:

"cognitive defecate". After almost peeing my pants laughing I showed it to her...she said...Yah...they are demented. Defecate???? Did you mean sh** for brains. All these years later I still tease her.

KingDom · Dec 10, 2008

We admitted a resident who was in relatively good health (for being in her late 90's). She was no longer safe to take care of herself at home due to weakness and debility.

When we asked the physician for an admitting diagnosis when he came in for rounds that day, he simply wrote, "she's old". I wanted to ask him what the ICD-9 code for that was!

flashpoint · Dec 10, 2008

A new CNA once charted...

Mary Smith (a short poem)

Mary's gait is unsteady.

Mary is likely to fall.

Mary may get hurt if we aren't ready.

That wouldn't be good at all.

And then he "signed" his name in a huge symbol (like the artist formerly known as Prince used) in bright orange ink.

rnlately · Dec 10, 2008

A new CNA once charted...
Mary Smith (a short poem)
Mary's gait is unsteady.
Mary is likely to fall.
Mary may get hurt if we aren't ready.
That wouldn't be good at all.
And then he "signed" his name in a huge symbol (like the artist formerly known as Prince used) in bright orange ink.

That's scary. I don't know what else to think about that.

KingDom · Dec 11, 2008

We have an Indian doctor who dictates his assessment to be typed up later. Because of his heavy accent, words are often mispelled. On confused residents he often starts with "significant memory loss", but frequently gets transcribed as "significant mammary loss" :chuckle