Using Creative Charting...

[luv2rsq]

Just wondering if there is anything that you have ever "creatively charted"? I had a pt awhile ago who had a SBO and had a projectile emesis. My charting went something like this... Pt had approx 500cc brown emesis, 200cc of which was collected in the emesis bag and the rest was distributed throughout the room". My coworker heard me chuckle as I was charting... I had to share!

[CompleteUnknown]

I have been worried that with the introduction of computer charting, the medical record was becoming a bland boring document consisting entirely of objective facts and figures with no indication whatsoever of the unique circumstances of each event or of the personality of the patient and those caring for him/her. I love the richness of words and the nuances that can be conveyed in a couple of phrases so the OP's entry in the patient's chart makes me very happy! :)

[CompleteUnknown]

Viva, that reminds me of a frequent faller I looked after who we had managed to keep off the floor for just over a week. The doctor's entry looked like this:

1400: Stable. No falls since last review.

1430: Famous last words. Fall at 1410.

[VivaLasViejas, ASN, RN]

BWAAAAAAHAHAHAHAHA!!!!!:rotfl:

That's why I try never to speak of how long it's been since so-and-so's last fall......it jinxes 'em every time!

[Nurse Leigh]

this thread reminds me of a physician who was putting in cpoe orders for one of his pts. after he was gone, we looked over the orders and had a good laugh. they went something like this:

vitalsperroutine

applyoxygenpernasalcannulatokeepsatsabove91%

..........etc.......

and finally,

(nsg)havesomeonefixthiskeyboard'sspacebar!!!!

one of the funnier things i've seen.....

[TeenyTinyBabyRN, BSN, RN]

Does sacrum/sacral area work for butt crack?

[wooh, BSN, RN]

medial to buttocks?

[CT Pixie, BSN, RN]

butt cleavage? Or maybe it's more correct term...buttock cleavage.

[cav5]

One thing I can say for school nursing is that the charting is never dull:

Stomach ache X this morning since getting dressed...........pants on backwards, fixed and pain level returned to zero...

Small acorn up R. nostril-easily removed by blowing nose (could not think of a different way of saying that)

Patient C/O being completely blind since coming to school. Vision exam 20/20 etc...says his sub "is the devil".

I can go on an on and on.....

I really love these kids!!

[Been there,done that, ASN, RN]

Hahahah. I had a patient as a new grad with Priapism. Not only didn't I know what to chart.... I didn't know how frequently to peek under the blanket to do my assessment.

Think I may have been a little more pc with "erection persists".

For any body waiting to jump on this..I am perfectly aware of the condition and how painful it can be. I still take care of men in Sickle Cell Crisis. They are not in pain when I am their nurse.

[groanup]

Charting While Tired...

While working nights I once charted that a pt's urine was "clear to auscultation".

A co-worker documented someone's stool as "brown and beautiful".

We caught these beauties and corrected them.

A resident once charted that a dying patient was "CTD".

As a student I struggled to describe drainage that was "pus- like" (think

"haze- like" vs. "hazy", or "water- like" vs. "watery") and found "purulent"

in my Taber's. Oh Happy Day!

I found this adorable little link to some "charting bloopers" courtesy

of our lovely doctors. It is NOT anything I put up:

Medical Charting Bloopers

================ ~ : ^ /' ================================

* *

==============

[kellenl]

We have a medical director who will decribe patient using made up abbreviations.

" 54 year old AAF, CAS"= 54 year old african american female, crazy as ****." lololol

We also have a made up code for the OR suites=code brown. It's when a patient gets a little Versed/Fentanyl combo and loose their bowels.

[backtowork]

or..pitching a perpetual tent..lol