Knowledge Activity: Introduction to Chart

Deficiencies (Associate)
Learning objectives
1. Analyze the documentation in the health record to ensure it supports the diagnosis and
reflects the patient's progress, clinical findings, and discharge status (4)
2. Verify the documentation in the health record is timely, complete, and accurate (4)
3. Identify a complete health record according to organizational policies, external
regulations, and standards (3)
4. Develop appropriate physician queries to resolve data and coding discrepancies (6)

Student instructions
1. If you have questions about this activity, please contact your instructor for assistance.
2. You will review the chart of Jacy Sky Redbird to complete this activity. Your instructor
has provided you with a link to the Introduction to Chart Deficiencies (AS) 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).

Glossary
Physician query: Written communication from a coder to a physician to request additional
clarification regarding information that is present or missing from the documentation to
improve the accuracy of coding. (Richards, 2015)

The activity
Perform a thorough review of Jacy Sky Redbird’s EHR, clicking on each tab and reading each
note. Then, use the following information to assist in completing the form below after
reviewing Jacy Sky Redbird’s chart.

Identify which items are present or deficient in Jacy Sky Redbird’s chart.
o Present: The relevant information is documented in the patient’s chart
o Deficient: The relevant information is not documented in the patient’s chart
o Not applicable: The information is not relevant to the patient or the care they
are receiving

EHR Go Knowledge Activity: Introduction to Chart Deficiencies (Associate) AK1006.7

Archetype Innovations LLC ©2022 1
EHR Go Knowledge Activity: Introduction to Chart Deficiencies (Associate) AK1006.7
Archetype Innovations LLC ©2022 2
 Questions
Highlight the correct choice for each numbered question below. Only select one answer per
question.
Overview
1. Allergies identified or No Known Allergies identified
a. Present
b. Deficient
2. Documentation of Advance Directive(s) status
a. Present
b. Deficient
Data Elements
3. Sex identified
a. Present
b. Deficient
4. Race/Ethnicity identified
a. Present
b. Deficient
5. Residence identified
a. Present
b. Deficient
6. Hospital ID# (SSN or MR#) present
a. Present
b. Deficient
7. Birth weight of newborn
a. Present
b. Deficient
c. Not applicable
8. Admission Date
a. Present
b. Deficient
9. Type of Admission listed
a. Outpatient
b. Inpatient
10. Expected source of payment listed (guarantor and/or insurance information)
a. Present
b. Deficient

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Problems
The diagnosis, problem and/or reason for admission may be found on the Problems tab, the
Admit order on the Orders tab, or the Admission H&P on the Notes tab.
11. Principal diagnosis listed
a. Present
b. Deficient
12. Other diagnosis listed
a. Present
b. Deficient
13. Reason for admission listed
a. Present
b. Deficient
Physician orders
14. Physician orders signed by ordering physician
a. Present
b. Deficient
Admit orders
15. Admit order written
a. Present
b. Deficient
16. Signed by ordering physician
a. Present
b. Deficient
Discharge order
17. Discharge order listed
a. Present
b. Deficient
18. Signed by ordering physician
a. Present
b. Deficient
Physician discharge summary
19. Physician discharge summary listed
a. Present
b. Deficient

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 20. Signed
a. Present
b. Deficient
21. Final Diagnosis noted
a. Present
b. Deficient
22. Principal operation or procedure noted
a. Present
b. Deficient
23. Admitting diagnosis noted
a. Present
b. Deficient
24. Summary of hospital course noted
a. Present
b. Deficient
25. Summary of lab and diagnostic testing noted
a. Present
b. Deficient
26. Discharge and aftercare instruction noted
a. Present
b. Deficient
27. Condition of patient at discharge noted
a. Present
b. Deficient
28. Disposition of patient noted
a. Present
b. Deficient
Physician History and Physical
29. Chief complaint
a. Present
b. Deficient
30. Relevant histories
a. Present
b. Deficient
31. Review of systems
a. Present
b. Deficient

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 32. Physical exam
a. Present
b. Deficient
33. Impression/differential diagnosis
a. Present
b. Deficient
34. Plan for treatment
a. Present
b. Deficient
35. Which physician would be queried regarding any missing or deficient information in the
History and Physical?
a. Kerry West, MD
b. Ji-young Sun, MD
Daily physician progress report
36. Daily physician progress or SOAP notes
a. Present
b. Deficient
Consent for treatment
37. Consent for treatment signed by patient or representative
a. Present
b. Deficient
38. Consent for treatment signed by physician
a. Present
b. Deficient
Consent for procedure
39. Consent for procedure signed by patient or representative
a. Present
b. Deficient
40. Consent for procedure signed by physician
a. Present
b. Deficient
Anesthesia/Surgery
41. Anesthesia report and evaluations
a. Present
b. Deficient

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 c. Not applicable
42. Operative/surgical report
a. Present
b. Deficient
c. Not applicable
Nurse notes
43. Nurse admission note
a. Present
b. Deficient
44. Nurse discharge note
a. Present
b. Deficient
45. Nurse daily assessment, progress note, patient change in status
a. Present
b. Deficient
Lab report/results
46. Complete Metabolic Panel results listed
a. Present
b. Deficient
47. CBC with Differential results listed
a. Present
b. Deficient
48. Lipid Profile results listed
a. Present
b. Deficient
49. Urinalysis results listed
a. Present
b. Deficient
50. Triacylglycerol lipase results listed
a. Present
b. Deficient
51. Ammonia results listed
a. Present
b. Deficient
52. Hemoglobin A1C results listed
a. Present
b. Deficient

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Pathology report/results
53. Pathology report/results listed (Pathology report is a document that includes a diagnosis
determined by examining cells and tissues under a microscope.)
a. Present
b. Deficient
c. Not applicable
Radiology report/results
54. Radiology test listed
a. Ultrasound
b. CAT scan - Abdomen/Pelvis with and without contrast
55. Reason for exam listed
a. Present
b. Deficient
56. Impression listed
a. Present
b. Deficient
57. Findings listed
a. Present
b. Deficient
Physical/Respiratory/Occupational/Speech/Nutrition Therapy notes
58. Therapy note NOT documented for
a. Dietetics
b. Respiratory Therapy
c. Occupational Therapy
59. Corresponding consult order on Orders tab for Respiratory Therapy note
a. Present
b. Deficient
60. Corresponding consult order on Orders tab for Dietetics note
a. Present
b. Deficient

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.

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 References
Richards, C. G. (2015, April 28). Libman Education. Retrieved from
https://www.libmaneducation.com/physician-query-process-part-1-physician-query-basics-and-
when-to-query/