Using Creative Charting...

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.

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.....

Does sacrum/sacral area work for butt crack?

medial to buttocks?

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

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:

Medical Charting Bloopers

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

* *

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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.

or..pitching a perpetual tent..lol

I had a pt fall out of his chair and land face first on concrete and tile floor. I was the nurse taking notes/giving orders, etc. At the top of my notes, I wrote "Resident face planted and hit lt side of face. Unresponsive. Dude didn't even respond to sternal rub"

I completely forgot that I wasn't going to transcribe this note, it was going in his chart. thankfully my DON and admin found it amusing.