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. Go online using your preferred browser and search for ISMP’s List of Error-
Prone Abbreviations, Symbols, and Dose Designations. Or use the following
link, http://www.ismp.org/tools/errorproneabbreviations.pdf Review the
contents for assistance in completing this activity.
2. Go online using your preferred browser and search for Taber’s Online Medical
Dictionary. Or use the following link, http://www.tabers.com/tabersonline/
view/Tabers-Dictionary/767492/0/Medical_Abbreviations Review the contents
for assistance in completing this activity.

EHR Go1 Knowledge Activity: EHR Documentation Standards AK1003.5

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 The activity
Student name: __Julie Khmelchenko__________________

Apply your knowledge

Review the Admission H&P on the Notes tab of Neveah Williams’ chart to answer the
following questions.

1. In the note, 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 & Physical

b. In Neveah’s Admission H&P, what is the chief complaint? Abdominal pain,

fever, loose/mucousy diarrhea, loss of appetite and subsequent
dehydration. 
c.

2. Neveah has a history of Dyskinetic Cerebral Palsy. What is Cerebral Palsy? A

condition marked by impaired muscle coordination (spastic paralysis) and/or
other disabilities, typically caused by damage to the brain before or at birth.

3. What does the abbreviation ETOH stand for? Ethyl alcohol

4. What does the abbreviation NKA stand for? No Known Allergies

5. Where else is NKA listed in this patient’s chart? On patient’s overheard as the
alert

6. What does the abbreviation HTN stand for? Hypertension

EHR Go2 Knowledge Activity: EHR Documentation Standards AK1003.5

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 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? Gross Motor Function
Classification System. GMFCS looks at movements such as sitting, walking and
use of mobility devices.

8. What is the difference between the Review of Systems and the Physical
Assessment sections of the H&P written by the physician?
Review of Systems contains a list of systems of the body, such as:
constitutional, eyes, ent, cardiovascular, respiratory, gastrointestinal,
genitourinary, musculoskeletal, skin and/or breast, neurologic, psychiatric,
endocrine, hematologic/ lymphatic, and allergic/immunologic. It’s a check
list to document normal or abnormal events of a patient.
Physical Assessment, is a physician’s check list to observe a patient symptoms
whether they are okay or not. A list consists of: vitals, general survey,
integumentary, hint, neck and lymph, cardiovascular, pulmonary, abdomen,
musculoskeletal, neurologic, genitalia & rectum, and recent labs.

9. Neveah is ultimately admitted for gastroenteritis. What is gastroenteritis?

Gastroenteritis is inflammation of the stomach and intestines, typically
resulting from bacterial toxins or viral infection and causing vomiting and
diarrhea.

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 a safe abbreviation to use in this context because it is talking about
clothing and not about profession.
11.Under Medications, Immunizations, Allergies, the nurse writes “Depakote
sprinkles: 80mg PO BID 0900, 2100.” What does “PO BID” mean? Take Orally
before Bedtime.

EHR Go3 Knowledge Activity: EHR Documentation Standards AK1003.5

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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.

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? INPUT/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. It’s most likely written as 1mg, so a
patient would not confuse it as 10mg. The goal here is to prevent overdosage.

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, it’s acceptable abbreviation because
the goal is to measure liquid, and mL is an ideal measuring system for that.

18.Neveah’s weight and height/length are listed in “lb” and “in.” Answer the
following questions.
a. “lb” is the abbreviation for _pounds_______.
b. “in” is the abbreviation for ___inch______.
c. 46 lb converts to ____21.8652____ kilograms (kg).
d. 41 in converts to ___104.14_____ centimeters (cm).

EHR Go4 Knowledge Activity: EHR Documentation Standards AK1003.5

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 Questions
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:
• Be accurate
• Be timely
• Be detailed
• Be documented according to national standards
• Use accepted abbreviations and terminology
• Follow facility policy
• Reflect individualized patient care
• Be unbiased

After reviewing a patient’s chart, the healthcare team should have enough
information to care for the patient, determine appropriate needs and administer
care. That is, IF everything that was done (i.e. assessments, tests, medications, skin
care and so on) was documented in the patient’s chart. The chart should paint a
thorough picture of the patient.

An example of good communication documented through the EHR would be Dr.

Lamar’s H&P. 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, 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.

EHR Go5 Knowledge Activity: EHR Documentation Standards AK1003.5

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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.
What type of blood work was ordered?
When it was ordered ?
Why is there no time line for the administration of IV, drugs, and time of urine output?
How long has a patient been observed for ?

Submit your 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.

References
Documentation Requirements for the Medical Record. (2014). Banner Health.
Retrieved from https://www.bannerhealth.com/-/media/files/pdfs/for-
physicians/documentationrequirementsforthemedicalrecord134245.pdf?la=en.

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

Taber’s Online medical dictionary (2015). Unbound Medicine. Retrieved from http://
www.tabers.com/tabersonline/view/Tabers-Dictionary/767492/0/
Medical_Abbreviations

EHR Go6 Knowledge Activity: EHR Documentation Standards AK1003.5

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