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Documentation

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Me_in_cocceticut_max50

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Posted almost 2 years ago

 

These are purported to be actual writings from various hospital charts.


1. The patient refused an autopsy.


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2. The patient has no previous history of suicides.


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3. Patient has left white blood cells at another hospital.


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4. She has no rigours or shaking chills, but her husband states she was very hot in bed last night.


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5. Patient has chest pain if she lies on her left side for over a year.


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6. On the second day, the knee was better, and on the third day it disappeared.


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7. The patient is tearful and crying constantly. She also appears to be depressed.


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8. The patient has been depressed since she began seeing me in 1993.


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9. Discharge status: Alive but without permission.


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10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.


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11. Patient had waffles for breakfast and anorexia for lunch.


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12. She is numb from her toes down.


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13. While in ER, she was examined, x-rated, and sent home.


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14. The skin was moist and dry.


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15 Occasional, constant infrequent headaches.


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16. Patient was alert and unresponsive.


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17. Rectal examination revealed a normal size thyroid.


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18. She stated that she had been constipated for most of her life, until she got a divorce.


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19. I saw your patient today, who is still under our car for physical therapy.


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20. Both breasts are equal and reactive to light and accommodation.


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21. Examination of genitalia reveals that he is circus sized.


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22. The lab test indicated abnormal lover function.


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23. Skin: somewhat pale but present.


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24. The pelvis exam will be done later on the floor.


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25. Patient has two teenage children, but no other abnormalities.


 

Humpback_whale_max50

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+1

Rated: +1 | Posted almost 2 years ago

 

OMG, Teresah!!!!!! These are so silly, but cute!!!!! Breasts equal and reactive to light, too funny!!!!!!!  I can believe they are from actual charts!!!!

Me_in_cocceticut_max50

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+1

Rated: +1 | Posted almost 2 years ago

 

No doubt, The bad thing about this is , it's actually true..LOL

Ashley_and_dad_max50

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Rate This | Posted almost 2 years ago

 

I am sure that Teresa and a few others remember when pregnancy would be listed as a disorder or problem on the problem list.


Tom, PhD, MPH, BS(N), RN-C, CHN

Melanie_s_wedding_2_max50

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Rate This | Posted almost 2 years ago

 

LOL... Teresa those are too funny! I'm definitely proofreading my documentation to be sure I don't write anything that outrageous. Thanks for sharing!


"When you're a nurse you know that everyday you will touch a life or a life will touch yours." author unknown
missLPN... Michele

Me_in_cocceticut_max50

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Rate This | Posted almost 2 years ago

 

Not only is documentaion extrmely imported. I tell my students to draw a line to the other sid of the line. This way noone can add to your thoughts

Teresa Hopins RNBSN-----------------------------------------------------------------------------------------------------------------

Winter_max50

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Rate This | Posted almost 2 years ago

 

Our nurse manager gave us this list at a staff meeting. I laughed so hard I had to step out of the meeting.

Me_in_cocceticut_max50

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Rate This | Posted almost 2 years ago

 

I'm so glad every one is so enterained by the original documations..


However, And I'm sure Dr. Tom will agree. This stuff happens. But such silly errors can bring you to court and you will lose you shirt. Be safe and be careful. And please take credit for what you have done, by documentation.


Hugs,Teresa..Court is not a good thing that you'd like to attend.

Photo_user_blank_big

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Rate This | Posted almost 2 years ago

 

" Sad,but true.Sometimes you will see this documentation in charts.Thanks for the proofreads.LMAO."


 

Me_in_cocceticut_max50

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Rate This | Posted almost 2 years ago

 

No prob...Hugs, Teresa

Me_in_cocceticut_max50

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Rate This | Posted over 1 year ago

 

The problem with thse errors is that they can be used in court..Be careful.. Hugs,Teresa