Nursing documentation does it again

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Jacqueline Vance, RNC, CDONA/LTC
Jacqueline Vance, RNC, CDONA/LTC

Let's face it. Nursing documentation can get you in trouble with your supervisor, make a surveyor faint, make a lawyer rich or make blog readers laugh. I'm going for the last here.

So doing a search, I found these “interesting” nursing notes. I would love it if you would share some of the weirdest ones you've come across in the comment section below.

Oh, I hope you're wearing your adult brief. I mean, come on guys — nursing notes are part of the actual medical record. I don't think any of the nurses who wrote these notes below would be much assistance in getting their facility to a Quality Award!

Just plain strange

•  “Cough with a flame” (The patent is a dragon? Seriously, what the heck!)

•  “Advised patient to take a bath” (Really, someone put this in the medical record?)

•  “Occasional, constant, infrequent headaches.” (Pick one, just one!)

•  “Patient has chest pain if she lies on her left side for over a year.” (Yeah, if I lay on one side for a year, my chest would hurt too.)

•  “While in ER, she was examined, X-rated and sent home.” (What happens in the ER, stays in the ER!)

•  “The lab test indicated abnormal lover function.” (I had no idea a there was a lab test for this. Could have saved me a lot of problems in my single days. Just saying.)

•  “She slipped on the ice and apparently her legs went in separate directions in early December.” (It's July. Did we find the legs yet, or is one in L.A. and one in Florida?)

•  “By the time he was admitted, his rapid heart had stopped and he was feeling much better.” (I'm not too sure you'd be feeling that great if your heart stopped, but let's go with it.)

•  “The patient is a 79-year-old widow who no longer lives with her husband.” (OK, good. We don't need another Norman Bates now, do we?)

Scariest

•  “Pt complained she had stroke. Tested by giving glass of water to see if patient could swallow. Water swallowed. No more complaints.” (Yup, that's exactly what the nursing textbook says how to check if someone has a stroke. NOT! I wonder if the patient didn't complain because he or she was dead.)

•  “Regulated IVF to KVO to run for 2 hours” (Basic math FAIL)

•  “Admission orders received for patient: Bisacodyl suppository by mouth for constipation.” (BLECHHH!)

•  “IVF consumed and terminated then replaced with the same IVF” (What, wait, what?)

•  “With 02 inhalation via Foley bag catheter attached to urobag.” (No words …)

•  “The patient will need disposition, and therefore we will get Dr. XX to dispose of him” (Why do I hear the theme of “The Godfather” playing in the background)

•  “He had a left-toe amputation one month ago. He also had a left-knee amputation last year.” (I'm really good with anatomy, but if the leg went first, where was the toe?!)

Worst spelling and worst made-up acronyms

•  “pt were up in hallway when he fof. too cnas at side. no injuries.” (OK, I give up, what's a FOF? How do you FOF?)

•  “Foley cateter were in place at beginning at shift. found pipe on floor. dr informed. (Cateter Pipe? I really don't want to know)

But the winner is:

•  “She has no rigors or shaking chills, but her husband states she was very hot in bed last night”

Just keeping it real,

Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, an APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. She has not starred in her own national television series — yet. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.

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The Real Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, a 2012 APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.

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