EHR GO Flashcards

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?

hypertension Signup and view all the answers

What does PO BID indicate?

by mouth twice a day Signup and view all the answers

What does WNL mean?

within normal limits Signup and view all the answers

What does RLE refer to?

right lower extremity Signup and view all the answers

What does AROM stand for?

active range of motion Signup and view all the answers

What does NPO mean?

nothing by mouth Signup and view all the answers

What does Strict I/O refer to?

strict intake and output Signup and view all the answers

Good documentation should be?

consistent and coordinated, complete, accurate, timely, objective, use of accepted abbreviations and terminology Signup and view all the answers

What is a CIWA scoring?

Clinical Institute Withdrawal Assessment Signup and view all the answers

Which tab in EHR Go contains subcategories problems, alerts, meds, and labs?

health tab Signup and view all the answers

Medications ordered for a patient is found both under the medication & _________ tab.

orders Signup and view all the answers

Where do alerts go?

in the patient header Signup and view all the answers

The patient header allows:

the healthcare team to easily view her alerts at first glance Signup and view all the answers

Where can you view graphs?

vital tab Signup and view all the answers

Medline Plus was established by?

U.S. National Library of Medicine Signup and view all the answers

Where is Medline Plus located?

in the problems tab Signup and view all the answers

Where is the drug information portal?

orders tab, under resources section Signup and view all the answers

What happens when you click the word 'category'?

it sorts the list Signup and view all the answers

What is the best resource available in EHR Go to learn more about the medication?

Drug Information Portal Signup and view all the answers

What is the best resource available in EHR Go for learning more about this diagnosis?

MedlinePlus Signup and view all the answers

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?

Order sorting by Category Signup and view all the answers

What tool in EHR Go provides increased visibility to an allergy entered?

Automatic red alert symbol in patient header of EHR Signup and view all the answers

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!