Head Scratching Charting Errors

Alright, Wayward Nurses, let’s talk about something we’ve all encountered: the infamous charting error. You know what I mean. You’re reading through the previous shift’s notes, and BAM—there it is. That charting blooper that makes you laugh out loud and wonder if autocorrect was having a meltdown.

We’ve all been there. Rushing through a crazy shift, juggling tasks like a rodeo clown, and then it happens. Spellcheck can’t save the day, and we end up with chart notes that sound like a bad game of Mad Libs.

The Funniest Errors

Here are a few gems that might sound familiar:

• “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.”

These charting errors aren’t just funny—they’re a reminder that even in our most stressful moments, humor finds a way to sneak in. But let’s get real for a second. While these mistakes are good for a chuckle, they can also lead to confusion and miscommunication.

The Impact of Charting Errors

Errors in charting can have serious consequences:

• Patient Safety: Inaccurate information can lead to incorrect treatments or missed symptoms.
• Legal Issues: Mis-Documentation can become a legal nightmare.
• Professionalism: Consistent errors can reflect poorly on your attention to detail and professionalism.

Tips to Avoid Charting Errors

So how do we avoid these mishaps while we’re wrangling our duties? Here are a few tips:

1. Take Your Time: Easier said than done, right? But even a few extra seconds can make a difference.
2. Double-Check: Before you hit save, give your notes a quick once-over.
3. Use Templates: They can help ensure you don’t miss crucial information.
4. Ask for Help: If you’re unsure about something, don’t hesitate to ask a colleague.

Own Your Mistakes

And hey, if you do make a mistake? Own it. Correct it as soon as you notice and move on. We’re all human, and admitting our errors is a sign of strength, not weakness.

Laugh it Off

At the end of the day, it’s important to find the humor in our day-to-day chaos. Share your funniest charting errors with your colleagues, have a laugh, and then get back to being the rockstar nurse you are.

So, next time you spot a charting error, take a moment to smile. It’s a little reminder that even in the midst of our hectic schedules, we’re all in this rodeo together.

Keep those lasso skills sharp, stay vigilant, and remember: spellcheck is your friend, but double-checking is your partner. Happy charting, Wayward Nurses!

 

Refer a Friend!

Job Search

Taxes giving you anxiety?