Nurses Notes…Charting Errors
We have all been there at least once. Reading through the previous shifts charting, you’ve seen it. The nurse note charting error that makes you laugh out loud. When we are in a hurry or stressed, sometimes spellcheck isn’t enough.
OOPS! Moments
- “Patient ambulates independently in hell with a front wheeled walker.”
- “the patient may shower with assistants…”
- “The patient was prepped and raped in the usual manner.” Found on Post-op patient chart
- “Her pap smear was done on the floor.”
- “Shortness of breath on excretion.”
- “Patient lying in bed. Easily aroused” – the patient had a penile implant; easy mistake for a first-semester student.
- “Scrotal dressing intact” – when last seen was a sacral dressing.
- “Pedal pulses diminished” – which was reasonable, as both of the patient’s legs had been amputated.
- “Patient nauseated but refused anti-emetics as he stated he’d feel much better if he could just get it up.”
- “Patient found this nurse in bed hot and diaphoretic.”
- “Pt has been hospitalized for constipation twice within the last 60 days. Several tests were run, but nothing concrete came out.”
- “Large brown stool ambulating in the hallway.”
- The patient is awake and alert, with many visitors in bed.
- “She was sick after coming back from the zoo as she had eaten too many penguins.” (Chocolate bars)
- “The patient states that he has been feeling much better since he stopped drinking and going to church.”
- “She is numb from her toes down.”
What nurse note charting errors have you found? Share your humorous finds in the comments below.
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Need some tips on Charting?
- Electronic Health Records – Tips For Making Electronic Charting Easier
- Charting Made Easy: The SOAPI Note
- and for more FUN: Medical Charting Bloopers
