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?◻
EHR Go Knowledge Activity: EHR Documentation Standards
AK1003.8
messages.pdf_cover_qr_code_label
iaersrshaegae,s .ldoosws nolofaadepdp_ebtyite, and
Acute abdominal pain, fever, loose/ mucousy dm
subsequent dehydration.
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?◻
EHR Go Knowledge Activity: EHR Documentation Standards
AK1003.8
messages.pdf_cover_qr_code_label
iaersrshaegae,s .ldoosws nolofaadepdp_ebtyite, and
Acute abdominal pain, fever, loose/ mucousy dm
subsequent dehydration.
