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Understanding the Patient's Chart

This folder includes clinical Q&A on a patient case involving cerebral palsy, medical abbreviations, functional assessments, and gastroenteritis—useful for students in nursing, health science, or medical terminology courses.

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    T h e activity Review the patient's chart as directed below to answer the following questions. Q u e s t i o n s 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. I t is sometimes in the patient's own words, enclosed in quotes. 1. What does H&P stand for? - H&P stands for History and Physical Exam 2- in Neveah's Admission H&P. what is the chief complaint? - acute symptoms of abdominal pain, fever, loose/mucousy diarrhea, loss of appetite dehydration EHR Go Knowledge Activity: EHR Documentation Standards AK1OO3.8 Archetype Innovations LLC ©2022 1

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    3. Neve ah 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 that affects body movement and muscle coordination 4- What does t h e 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.) ETOH stands for ethyl alcohol 5. What does t h e a bb reviatio n NKA stand for? NKA stands for n o known aIle rgi es 6- Where else is NKA listed in this patient's chart? it is listed under Alerts 7. What does t h e a bb reviatio n HTN sta n d fo r? HTN stands for hypertension 8- In the Functional Status section of the note it states, "Mother reports patient assessed at G MFCS Level III - walks with adaptive equipment assistance." What does GM FCS stand for and what is the test used for? Gross Motor Function Classification System 9. What is the difference between the Review o f Systems and the Physical Examination sections of the H&P written by the physician? main difference between the review of systems and physical examination is that review of systems is subjective and physical examination is objective 10. Neveah is ultimately admitted for gastroenteritis. What is gastroenteritis? Gastroenteritis (stomach flu) caused by a bacterial o r viral t u m m y bug. (inflammation of the stomach and intestines) Review the Nursing Admission Assessment note o n the Notestab of Neveah's chart t o answer the following questions. 11. 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 Medico) Dictionary' DC stands for Doctor of Chiropractic or direct current. Based o n this information, do you think DC is a goodor safe abbreviation t o use? Why or why not? no. DC is not a safe abbreviation to use because it has so many meanings such as discontinue, direct cur re nt, or doctor of chiropractic 12. Under Medications. Immunizations, Allergies, the nurse writes "Depakote sprinkles: SOmg PO BID 0900, 2100." What does "PO BID" mean? (Hint: Refer to the resource titled Medical Abbreviations Taber's Medical Dictionary found under 1 : Overview & Resources along with this activity document.) EHRGc Knowledge Activity: EHR Documentation Standards AK1003.E Archetype Innovations LLC ©2022 2

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