Published
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!
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.....
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!!
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.
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:
================ ~ : ^ /' ================================
* *
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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.
CompleteUnknown
352 Posts
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! :)