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 & Physical
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
, ● This patient is an 8 year old female with cerebral palsy being admitted to the
Pediatric unit from the family physician clinic for acute symptoms of abdominal
pain, fever, loose/mucousy diarrhea, loss of appetite and subsequent
dehydration. The patient is accompanied by the mother who states, "She's not
acting like herself, I'm worried she may be getting dehydrated with all of the
diarrhea she's having".
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.)
● Cerebral palsy is a static neurologic condition resulting from brain injury that
occurs before cerebral development is complete.
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.)
● ethyl alcohol
5. What does the abbreviation NKA stand for?
● no known allergies
6. Where else is NKA listed in this patient’s chart?
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. This tool is used to assess the gross motor
functions of children with cerebral palsy.
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?
● Gastroenteritis is an inflammation of the lining of the stomach and intestines.
EHR Go Knowledge Activity: EHR Documentation Standards AK1003.8
Archetype Innovations LLC ©2022 2
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 & Physical
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
, ● This patient is an 8 year old female with cerebral palsy being admitted to the
Pediatric unit from the family physician clinic for acute symptoms of abdominal
pain, fever, loose/mucousy diarrhea, loss of appetite and subsequent
dehydration. The patient is accompanied by the mother who states, "She's not
acting like herself, I'm worried she may be getting dehydrated with all of the
diarrhea she's having".
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.)
● Cerebral palsy is a static neurologic condition resulting from brain injury that
occurs before cerebral development is complete.
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.)
● ethyl alcohol
5. What does the abbreviation NKA stand for?
● no known allergies
6. Where else is NKA listed in this patient’s chart?
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. This tool is used to assess the gross motor
functions of children with cerebral palsy.
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?
● Gastroenteritis is an inflammation of the lining of the stomach and intestines.
EHR Go Knowledge Activity: EHR Documentation Standards AK1003.8
Archetype Innovations LLC ©2022 2
