EHR+Documentation+Standards+AK1003 PDF

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EHR Documentation Standards...

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Knowledge Activit Activity: y: EHR Documentation Standard Standardss Learning objectiv objectives es 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 activit activity y Student name: Maria Fenandes-Depina

Questions Review the Admission H&P on the Notes tab of Neveah Williams’ chart to answer the following questions. EHR Go Knowledge Activity: EHR Documentation Standards AK1003.7 Archetype Innovations LLC ©2019

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1. 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. a .What does H&P stand for? -

History and Physical

b .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. the mother states, “She's not acting like herself, I'm worried she may be getting dehydrated with all of the diarrhea she's having”. 2. Neveah has a history of Dyskinetic Cerebral Palsy. What is Cerebral Palsy? - Cerebral palsy is a group of disorders that affect a person's ability to move and maintain balance and posture.

3. What does the abbreviation ETOH stand for? - ETOH= Ethyl Alcohol 4. What does the abbreviation NKA stand for? - NKA= No Known Allergies 5. Where else is NKA listed in this patient’s chart? -

NKA is located in the Overview tab under alerts or in Alerts tab.

6. What does the abbreviation HTN stand for? - HTN = Hypertension 7. 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? - GMFCS= Gross Motor Function Classification System; The test is used for classifying the movement ability of children with cerebral palsy. EHR Go Knowledge Activity: EHR Documentation Standards AK1003.7 Archetype Innovations LLC ©2019

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8. What is the difference between the Review of Systems and the Physical Examination sections of the H&P written by the physician? Review of systems is the historical review of the patient's complaints specific to each body system and Physical examination focuses on the characteristics of the illness that are objective.

9. Neveah is ultimately admitted for gastroenteritis. What is gastroenteritis? - An intestinal infection marked by diarrhea, cramps, nausea, vomiting, and fever. Review the Nursing Admission Assessment note on the Notes tab of Neveah’s chart to answer the following questions. 10. 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? - DC is not a safe abbreviation, although we understood what the note meant the acronym has several meanings.

11. Under Medications, Immunizations, Allergies, the nurse writes “Depakote sprinkles: 80mg PO BID 0900, 2100.” What does “PO BID” mean? - Taken by mouth; Twice a Day. Review the Occupational Therapy Initial Evaluation note on the Notes tab of Neveah’s chart to answer the following question. 12. What do the following abbreviations stand for? a .WNL = ______Within Normal Limits___________________ b .RLE = ______Right Lower Extremity_____________________ c .AROM = ______Active Range of Motion__________________ Looking at the orders entered on the Orders tab of Neveah’s chart, answer the following questions. 13. Write out the ‘Location’ order without abbreviations. -Admit to pediatrics for Gastroenteritis rule-out dehydration. EHR Go Knowledge Activity: EHR Documentation Standards AK1003.7 Archetype Innovations LLC ©2019

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14. What does NPO stand for in the ‘Dietetics’ order? - Nothing by mouth. 15. Write out the ‘Screening/Measurements’ order, Strict I/O, without abbreviations. What does this order mean? - Strict input and output; It stresses the importance of recording and monitoring the intake and output. 16. The medication order benztropine mesylate 1 mg/mL (Cogentin) is ordered to give 1 mg. Why isn’t this entered as 1.0 mg? Wouldn’t having it entered as 1.0 mg be more accurate? Explain your answer. - 1.0 is not entered to avoid confusion on amount. No Looking at the measurements entered on the Vitals tab of Neveah’s chart, answer the following questions. 17. Neveah’s Intake and Output is listed as ml (or mL). Is this an acceptable abbreviation? Explain your answer. - Yes because it is the acceptable abbreviation for fluid. 18. Neveah’s weight and height/length are listed in “lb” and “in.” Answer the following questions. a .“lb” is the abbreviation for ___Pound_____. b .“in” is the abbreviation for ____Inches_____. c .Convert 46 lb to kilograms (kg). Show your calculation: 1k g=2. 2 04623l bs . 46/2.204623 = 20.8652kg Convert 41 inches to centimeters (cm). Show your calculation: 1 i n=2 . 54c m.41 *2. 54=1 04.

One of the most important features of an electronic health record is the ability to communicate through the patient’s chart with other members of the healthcare team. The communication can be done real time via the EHR, without speaking in-person and directly with other members of the healthcare team. Good chart documentation by all members of the team should:    

Consistency and coordination Completeness Accuracy Timeliness

EHR Go Knowledge Activity: EHR Documentation Standards AK1003.7 Archetype Innovations LLC ©2019

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 

Objectivity Use of accepted abbreviations and terminology

(MMIC, 2007). After reviewing a patient’s chart, the healthcare team should have enough information to provide quality care for the patient by determining the patient’s unique situation and needs and administering the appropriate care. An example of good communication documented through the EHR would be Dr. Lamar’s H&P in Neveah’s EHR. The doctor provides a clear explanation of why Neveah is at the hospital. When reading the Chief Complaint and the History of Present Illness, the nurses, Minh Vu and Cathy Rhoades, and the occupational therapist Maneesh Kapoor, do not have to speak with Dr. Lamar to know what brought the patient to the hospital and what the planned treatment is. An example of poor documentation, where there is not enough information given, is in the Nursing Progress Note written by Cathy Rhoades. Cathy entered, “Bloodwork drawn and sent.” The question would be, what is the bloodwork? To prevent having to ask this question, Cathy should have written this statement as, “CBC drawn and sent to lab.” This tells the reader (the healthcare team member) what lab was drawn and that the specimen was sent to the lab for processing. The date and time of the note would let the reader know approximately when this occurred. 19. Imagine you are part of the healthcare team caring for Neveah. As you have been reviewing her chart, you have found inconsistencies, or minimal information, and you are wanting to know more. This is information that you need to get a complete picture of her current status. List three questions that you have regarding Neveah’s status, her care or something that is missing from her chart. - Is there anything to be added in the prevention tab? - Should there be a discharge note? - The blood work in the Nursing Progress Note is not written yet or at least still pending?

Submit yyour our work Document your answers directly on this activity document as you complete the activity. When you are finished, save this activity document to your device and upload this activity document with your answers to your Learning Management System (LMS). If you have any questions about submitting your work to your LMS, please contact your instructor.

EHR Go Knowledge Activity: EHR Documentation Standards AK1003.7 Archetype Innovations LLC ©2019

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Re Referen feren ferences ces ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations (2013). Institute for Safe Medication Practices. Retrieved from http://www.ismp.org/tools/errorproneabbreviations.pdf MMIC Group. (2007). Medical Record Documentation. Retrieved from https://www.mmicgroup.com/PDF/MedRecDocument.pdf Taber’s Online medical dictionary (2015). Unbound Medicine. Retrieved from http://www.tabers.com/tabersonline/view/TabersDictionary/767492/0/Medical_Abbreviations

EHR Go Knowledge Activity: EHR Documentation Standards AK1003.7 Archetype Innovations LLC ©2019

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