Funniest thing ever.
These are called charting bloopers. They’re excerpts taken from real charts that nurses have written about patients. My roommated was given a list of them in one of her nursing classes to show what bad documentation is. They’re awesome so I typed them up.
The skin was moist and dry.
The patient lives at home with his mother, father and pet turtle, who is presently enrolled in day care three times a week.
Exam of genitalia reveals that he is circus sized.
The patient suffers from occasional, constant, infrequent headaches.
When she fainted, her eyes rolled around the room.
Te patient was alert and unresponsive.
While in the emergency room, she was examined, x-rated and sent home.
She is numb from her toes down.
Both breasts are equal and reactive to light and accommodation.
Rectal exam revealed a normal sized thyroid.
The patient had waffles for breakfast and anorexia for lunch.
The patient had rectal breathing,
The patient has no past history of suicides.
Patient left his white blood cells at another hospital.
Patient had a breast deduction.
Her boyfriend also apparently has vaginal warts.
Her husband is living in the nursing home next store.
The patient has difficulty swallowing pillows and has to turn her head to one side to do it.
No mobility limitations noted except for difficulty with transfers, standing, turning and ambulating (walking around, moving.)
The patient had large brown stool ambulating in the hall.
Patient was asked to breathe, but she refused.
Patient got hit in the head and received a confusion.
Plan…gently dehydrate.
His HCT is stable, but dropping.
Order: please feed patient only when awake.
Nursing notes in ICU chart…The M.D. is at bedside trying to urinate.
Nonaudible wheezing noted.
On the second day the knee was better and on the third day it had completely disappeared.
Patient has chest pains if she lies on her side for over a year.
Health appearing, decrepit 69 year old female.
Patient expired on the floor uneventfully.
The skin was moist and dry.
The patient lives at home with his mother, father and pet turtle, who is presently enrolled in day care three times a week.
Exam of genitalia reveals that he is circus sized.
The patient suffers from occasional, constant, infrequent headaches.
When she fainted, her eyes rolled around the room.
Te patient was alert and unresponsive.
While in the emergency room, she was examined, x-rated and sent home.
She is numb from her toes down.
Both breasts are equal and reactive to light and accommodation.
Rectal exam revealed a normal sized thyroid.
The patient had waffles for breakfast and anorexia for lunch.
The patient had rectal breathing,
The patient has no past history of suicides.
Patient left his white blood cells at another hospital.
Patient had a breast deduction.
Her boyfriend also apparently has vaginal warts.
Her husband is living in the nursing home next store.
The patient has difficulty swallowing pillows and has to turn her head to one side to do it.
No mobility limitations noted except for difficulty with transfers, standing, turning and ambulating (walking around, moving.)
The patient had large brown stool ambulating in the hall.
Patient was asked to breathe, but she refused.
Patient got hit in the head and received a confusion.
Plan…gently dehydrate.
His HCT is stable, but dropping.
Order: please feed patient only when awake.
Nursing notes in ICU chart…The M.D. is at bedside trying to urinate.
Nonaudible wheezing noted.
On the second day the knee was better and on the third day it had completely disappeared.
Patient has chest pains if she lies on her side for over a year.
Health appearing, decrepit 69 year old female.
Patient expired on the floor uneventfully.