Questions and Answers
What does H&P stand for?
history and physical
What does EtOH refer to?
ethyl alcohol
What does NKA mean?
no known allergies
What does HTN stand for?
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What does PO BID indicate?
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What does WNL mean?
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What does RLE refer to?
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What does AROM stand for?
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What does NPO mean?
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What does Strict I/O refer to?
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Good documentation should be?
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What is a CIWA scoring?
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Which tab in EHR Go contains subcategories problems, alerts, meds, and labs?
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Medications ordered for a patient is found both under the medication & _________ tab.
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Where do alerts go?
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The patient header allows:
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Where can you view graphs?
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Medline Plus was established by?
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Where is Medline Plus located?
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Where is the drug information portal?
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What happens when you click the word 'category'?
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What is the best resource available in EHR Go to learn more about the medication?
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What is the best resource available in EHR Go for learning more about this diagnosis?
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Which resource in EHR Go would allow you to see all the Scheduled Meds already entered in the patient's chart before you enter the new order?
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What tool in EHR Go provides increased visibility to an allergy entered?
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Study Notes
Medical Abbreviations and Definitions
- H&P stands for history and physical, an essential component in patient assessments.
- EtOH refers to ethyl alcohol, commonly known as alcoholic beverages.
- NKA indicates no known allergies, important for medication safety.
- HTN is the medical term for hypertension, a condition characterized by high blood pressure.
- PO BID means by mouth twice a day, a common medication administration instruction.
- WNL signifies within normal limits, used in documenting lab results and assessments.
- RLE stands for right lower extremity, specifying the anatomy involved in examinations.
- AROM is an acronym for active range of motion, assessing a patient's joint movement capabilities.
- NPO represents nothing by mouth, indicating a patient should not eat or drink before a procedure.
- Strict I/O stands for strict intake and outtake, a method of monitoring fluid balance in patients.
Documentation Quality
- Good documentation should be consistent and coordinated, ensuring clarity and accuracy in patient records.
- Documentation must be complete, accurate, timely, and objective while employing accepted abbreviations and terminology.
Clinical Tools and Resources
- CIWA scoring refers to the Clinical Institute Withdrawal Assessment, used for monitoring alcohol withdrawal symptoms.
- The health tab in EHR Go includes subcategories like problems, alerts, medications, and labs.
- Medications ordered for a patient can be found under both the medication and orders tab.
Alerts and Patient Header
- Alerts are displayed in the patient header, allowing quick access to critical information.
- The patient header enables the healthcare team to easily view alerts at first glance.
Data Visualization
- Graphs can be viewed in the vital tab, providing visual representation of a patient’s vital signs.
Educational Resources
- Medline Plus was established by the U.S. National Library of Medicine to provide health information.
- Medline Plus can be found in the problems tab, linking patients' diagnoses to valuable resources.
- The Drug Information Portal is accessible under the orders tab, useful for checking medication information.
User Functions in EHR Go
- Clicking on the word 'category' sorts the medication list, enhancing user navigation.
- The Drug Information Portal is the best resource for medication-related inquiries in EHR Go.
- MedlinePlus serves as the best resource for further learning about diagnoses in EHR Go.
- The Order sorting by Category feature allows users to view all scheduled medications before entering new orders.
- An automatic red alert symbol in the patient header highlights entered allergies, providing increased visibility.
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Description
Test your knowledge with these EHR GO flashcards covering essential medical abbreviations and terms. This quiz focuses on common acronyms like H&P, HTN, and more, which are vital in electronic health record documentation. Perfect for healthcare professionals and students alike!