Ehr Go Introduction To Chart Deficiencies Answers ((install)) -

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Always look for labels like "Draft," "Preliminary," or "Pending Signature."

: The item is entirely missing from the chart but is required for that patient's care. Not Applicable (N/A)

Compare the Nursing Flowsheet (08:00 AM) with the Progress Note (08:15 AM). What deficiency exists?

Failure to document the final status of a patient upon leaving the facility.

No, this is often the exact deficiency the lab wants you to identify. If the patient's orders or progress notes indicate a surgery took place, but no operative report exists in the documents tab, you must log "Missing Operative Report" as an active deficiency on your assignment sheet.

EHR Go: Introduction to Chart Deficiencies – Answers and Guided Walkthrough

Verifying it is completed upon patient release.

You cannot edit the doctor's work. Instead, right-click on the deficient document (e.g., an unsigned order) and select

Always look at the and Discharge Date first. Every regulatory deadline hinges on these two timestamps. Step 2: Navigate to the Notes Tab

| Deficiency Type | Example | |----------------|---------| | | No vital signs for a post-op patient | | Incomplete orders | PRN med order missing indication or max dose | | Unreconciled allergies | Allergy listed but no reaction type | | Discrepancies | Reported pain level (8/10) but no follow-up action | | Missing signatures | Unsigned nursing note or verbal order | | Outdated care plans | Care plan still lists “risk for falls” after patient is ambulatory |

Chart deficiencies are not just "paperwork errors." In a clinical environment, they directly affect patient safety and facility liability: