Ehr Go Knowledge Activity: EHR Documentation Standards Learning objectives Questions and Answers|Latest Update with complete solution

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. 1 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 2. In Neveah’s Admission H&P, what is the chief complaint? 3 ● 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".