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?
History and Physical
2. In Neveah’s Admission H&P, what is the chief complaint? acute symptoms of
abdominal pain, fever, loose/mucousy diarrhea, loss of appetite and
subsequent dehydration. Mother states, pt behavior is outside the norm,
mother is concerned pt is dehydrated due to multiple diarrhea episodes.
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
1
, along with this activity document.) Cerebral palsy is a group of neurological conditions
resulting from brain injury that occurs before cerebral development is complete that affect
movement, posture, and balance.
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.) ETOH is the abbreviation for Ethyl Alcohol.
5. What does the abbreviation NKA stand for? No known allergies.
6. Where else is NKA listed in this patient’s chart? In Overview and Alerts tabs.
7. What does the abbreviation HTN stand for? Hypertension
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? Gross Motor Function Classification System is a
5 level system for individuals with Cerebral Palsy used to describe movement abilities,
functional limitations and needs for assistive mobility devices.
9. What is the difference between the Review of Systems and the Physical Examination
sections of the H&P written by the physician? The review of systems and physical exam
is, ROS is subjective information based on what the physician’s was told by the mom. PE,
is objective information of the patient’s body, gathered by the physician’s hands on
examination.
10. Neveah is ultimately admitted for gastroenteritis. What is gastroenteritis? Inflammation
of the stomach lining and intestines that is caused by bacteria, viruses, or parasites.
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 Medical Dictionary DC stands for Doctor of Chiropractic or
direct current. Based on this information, do you think DC is a good or safe abbreviation
to use? Why or why not? No, because someone can easily confuse abbreviation with
“discontinue” which means to stop treatment or medication. It is required by hospitals
to spell out the word “discharge” to prevent errors.
12. Under Medications, Immunizations, Allergies, the nurse writes “Depakote sprinkles:
80mg PO BID 0900, 2100.” What does “PO BID” mean? (Hint: Refer to the resource titled
‘Medical Abbreviations Taber’s Medical Dictionary found under 1: Overview &
Resources along with this activity document.) By mouth, twice a day.
2
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?
History and Physical
2. In Neveah’s Admission H&P, what is the chief complaint? acute symptoms of
abdominal pain, fever, loose/mucousy diarrhea, loss of appetite and
subsequent dehydration. Mother states, pt behavior is outside the norm,
mother is concerned pt is dehydrated due to multiple diarrhea episodes.
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
1
, along with this activity document.) Cerebral palsy is a group of neurological conditions
resulting from brain injury that occurs before cerebral development is complete that affect
movement, posture, and balance.
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.) ETOH is the abbreviation for Ethyl Alcohol.
5. What does the abbreviation NKA stand for? No known allergies.
6. Where else is NKA listed in this patient’s chart? In Overview and Alerts tabs.
7. What does the abbreviation HTN stand for? Hypertension
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? Gross Motor Function Classification System is a
5 level system for individuals with Cerebral Palsy used to describe movement abilities,
functional limitations and needs for assistive mobility devices.
9. What is the difference between the Review of Systems and the Physical Examination
sections of the H&P written by the physician? The review of systems and physical exam
is, ROS is subjective information based on what the physician’s was told by the mom. PE,
is objective information of the patient’s body, gathered by the physician’s hands on
examination.
10. Neveah is ultimately admitted for gastroenteritis. What is gastroenteritis? Inflammation
of the stomach lining and intestines that is caused by bacteria, viruses, or parasites.
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 Medical Dictionary DC stands for Doctor of Chiropractic or
direct current. Based on this information, do you think DC is a good or safe abbreviation
to use? Why or why not? No, because someone can easily confuse abbreviation with
“discontinue” which means to stop treatment or medication. It is required by hospitals
to spell out the word “discharge” to prevent errors.
12. Under Medications, Immunizations, Allergies, the nurse writes “Depakote sprinkles:
80mg PO BID 0900, 2100.” What does “PO BID” mean? (Hint: Refer to the resource titled
‘Medical Abbreviations Taber’s Medical Dictionary found under 1: Overview &
Resources along with this activity document.) By mouth, twice a day.
2
