EHR GO Flashcards

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.