EHR Documentation Standards (2)

Question 1

Good chart documentation

Answer 1

• consistency and coordination
• completeness
• accuracy
• timeliness
• objectivity
• use of accepted abbreviations and terminology

Question 2

What does “PO BID” mean?

Answer 2

Orally twice a day.

Question 3

What does “NPO” mean?

Answer 3

Nothing by mouth

Question 4

What does “WNL” stand for?

Answer 4

Within normal limits

Question 5

What does “RLE” stand for?

Answer 5

Right lower extremity

Question 6

What does “AROM” stand for?

Answer 6

Active range of motion

Question 7

What does “Strict O/I” stand for?

Answer 7

Strict output and input

Question 8

What does “NKA” stand for?

Answer 8

No known drug allergies

Question 9

What does “HTN” stand for?

Answer 9

Hypertension

Question 10

What does “ETOH” stand for?

Answer 10

Ethyl alcohol

Question 11

What does “H and P” stand for?

Answer 11

History and physical

Question 12

What is cerebral palsy?

Answer 12

Is a static neurologic conditions resulting from brain injury that occurs before cerebral development is complete.

Question 13

What does “GMFCS” stand for And what is the test used for?

Answer 13

Gross motor function classification system for cerebral palsy. Standardized self-initiated movements and measure change in gross motor function over time, and this particular scale is widely accepted and easy to administer in the primary care office.

Question 14

What does “ROS” stand for?

Answer 14

Review of systems

Question 15

Review of systems

Answer 15

System set of questions asked of a patient regarding symptoms. They are experiencing.

Question 16

Physical examination

Answer 16

Hands-On, a routine test performed to check your overall health.

• inspection, palpation, percussion, and auscultation.

Question 17

What is gastroenteritis

Answer 17

Is an inflammation of the lining of the intestines caused by a virus, bacteria, or parasites.