ehr go Knowledge Activity: EHR Documentation Standards Learning objectives 1. Identify acceptable healthcare terminology. 2. Identify the roles and responsibilities of various providers and disciplines, to support documentation requirements. 3. Interpret patient's medical information as it's seen in the electronic health record. 4. Apply current knowledge of electronic health records and appropriate, accurate documentation. Student instructions 1. If you have questions about this activity, please contact your instructor for assistance. 2. You will review the chart of Neveah Williams to complete this activity. Your instructor has provided you with a link to the EHR Documentation Standards activity. Click on 2: Launch EHR to review the patient chart and begin this activity. 3. Refer to the patient chart and any suggested resources to complete this activity. 4. Document your answers directly on this activity document as you complete the activity. When you are finished, you will save this activity document to your device and upload this activity document with your answers to your Learning Management System (LMS). Suggested resources 1. Review the resources included with this activity under 1: Overview & Resources for assistance in completing this activity. Additional Internet or textbook resources may also be used. The activity Review the patient's chart as directed below to answer the following questions. Questions Review the Admission H&P note on the Notes tab in Neveah's chart. On the Notes tab, in the note titled Admission H&P, the "Chief Complaint" is one or two sentences listing either the patient's current symptoms or reason for seeking care. It is sometimes in the patient's own words, enclosed in quotes. 1. What does H&P stand for? 2. In Neveah's Admission H&P, what is the chief complaint? EHR Go Knowledge Activity: EHR Documentation Standards AK1003.8 Archetype Innovations LLC @2022 1
3. Neveah has a history of Dyskinetic Cerebral Palsy. What is Cerebral Palsy? (Hint: Refer to the resource titled 'Cerebral Palsy Overview" found under 1: Overview & Resources along with this activity document.) 4. What does the abbreviation ETOH stand for? (Hint: Refer to the resource titled 'Medical Abbreviations_Taber's Medical Dictionary found under 1: Overview & Resources along with this activity document.) 5. What does the abbreviation NKA stand for? 6. Where else is NKA listed in this patient's chart? 7. What does the abbreviation HTN stand for? 8. In the Functional Status section of the note it states, "Mother reports patient assessed at GMFCS Level III - walks with adaptive equipment assistance." What does GMFCS stand for and what is the test used for? 9. What is the difference between the Review of Systems and the Physical Examination sections of the H&P written by the physician? 10. Neveah is ultimately admitted for gastroenteritis. What is gastroenteritis? Review the Nursing Admission Assessment note on the Notes tab of Neveah's chart to answer the following questions. 11. Under the section, Personal Property and Assistive Devices, it is documented: "Kept by parent clothing wearable for DC." In this note, DC is intended to refer to discharge. According to Taber's Online