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Understanding the Patient's Chart - Document preview page 1

Understanding the Patient's Chart - Page 1

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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.

Daniel Miller
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Understanding the Patient's Chart - Page 1 preview imageT h e activityReview the patient's chart as directed below to answer the following questions.Q u e s t i o n sReview 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 twosentences listing either the patient's current symptoms or reason for seeking care. I t issometimes in the patient's own words, enclosed in quotes.1.What does H&P stand for?-H&P stands for History and Physical Exam2-in Neveah's Admission H&P. what is the chief complaint?-acute symptoms of abdominal pain, fever, loose/mucousy diarrhea, loss of appetitedehydrationEHR Go Knowledge Activity: EHR Documentation Standards AK1OO3.8Archetype Innovations LLC ©20221
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Understanding the Patient's Chart - Page 2 preview image3.Neveahhas a historyofDyskinetic Cerebral Palsy. What is Cerebral Palsy? (Hint: Refer tothe resource titled 'Cerebral Palsy Overview" found under 1 : Overview & Resourcesalongwiththis activity document.)Cerebral palsy is a static neurologic condition that affects body movement andmuscle coordination4-What does t h e abbreviationETOHstand for? (Hint: Refer totheresource titled 'MedicalAbbreviations_Taber’s Medical Dictionary found under 1 : Overview & Resources alongwith this activity document.)ETOH stands for ethyl alcohol5.What does t h e abbreviation NKA stand for?NKA stands for noknownaIlergies6-Where else is NKA listed in this patient's chart?it is listed under Alerts7.What does t h e abbreviationHTN stand for?HTN stands for hypertension8-In the Functional Status section of the note it states, "Mother reports patient assessedatG MFCS Level III - walks with adaptive equipment assistance." What does GM FCS standfor and what is the test used for?Gross Motor Function Classification System9.Whatis the difference between the Review o f Systems and the Physical Examinationsections of the H&P written bythephysician?maindifference between the review of systems and physical examination isthatreview of systems is subjective and physical examination is objective10.Neveah is ultimately admitted for gastroenteritis.Whatis gastroenteritis?Gastroenteritis (stomach flu) caused by a bacterial o r viral t u m m y bug. (inflammationof the stomach and intestines)Review theNursingAdmission Assessment note o n the Notestab of Neveah's chart t o answerthe following questions.11. Underthesection, Personal Property and Assistive Devices,it isdocumented: "Kept byparent 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 ordirect current. Based o n this information, do you think DC is a goodor safe abbreviationt o use? Why or why not?no. DC is not a safe abbreviation to use because it has so many meanings such asdiscontinue, direct cur rent, or doctor of chiropractic12. Under Medications. Immunizations, Allergies, the nurse writes "Depakote sprinkles:SOmg POBID0900, 2100." What does "PO BID" mean? (Hint: Refer to the resource titledMedical Abbreviations Taber's Medical Dictionary found under 1 : Overview & Resourcesalongwiththis activity document.)EHRGc Knowledge Activity: EHR Documentation Standards AK1003.EArchetype Innovations LLC ©20222
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