All charting errors starts with assessment, of course.
“On the second day, the knee was better, and on the third day it disappeared!”
“Patient has chest pain if she lies on her left side for over a year.”
“She is numbed from her toes down.”
“Cough with flame” (I guess that nurse’s patient was a dragon!).
And did you know that rectal exams can now reveal the size of your thyroid?
“Rectal examination revealed a normal sized thyroid”. Or maybe, that nurse has really long index finger.
Another thing, assessment cues like these can be really confusing:
“Skin: somewhat pale but present.”
“The skin was moist and dry.”
“Occasional, constant, infrequent headaches.”
“Patient was alert and unresponsive.”
“The patient has no previous history of suicides.”
“The patient has been depressed since she began seeing me in 1993.”
“She stated that she had been constipated for most of her life, until she got separated”, that patient’s marriage must be really awful, talk about getting a relief!
“Patient has two teenage children, but no other abnormalities”, DSM-V now indicates that having teenage children is an abnormality.
“The patient was to have a bowel resection. However, he took a job as a stockbroker instead.”
Weird Nursing Diagnoses
“Acute pain related to witchcraft”.
“Bowel incontinence related to shyness”.
“Insomnia related to computer games”.
Interventions & Others
“Discharge status: Alive but without permission.” I didn’t knew that hospitals now issue permissions for you to be alive.
“The patient refused autopsy.” – LOL
“With 02 inhalation via foley bag catheter attached to urobag.”
“Advised patient to take a bath”
“IVF consumed and terminated then replaced with the same IVF”
“Regulated IVF to KVO to run for 2 hours”
“While in ER, she was examined, X-rated and sent home.”
“The lab test indicated abnormal lover function.”
And the winner is:
“She has no rigors or shaking chills, but her husband states she was very hot in bed last night”.
Source: Google Brother