Missing Attestation/Signature . Rationale: The operative note is typed but shows "Electronically Signed: [DRAFT]" or has a blank line where the surgeon's e-signature should be. In EHR Go, a draft counts as a deficiency. Section B: Timeliness Violations (Delinquent Records) Question 3: According to the facility’s “Medical Staff Bylaws” (found in the Policy section of EHR Go), how many days does a physician have to complete an History & Physical (H&P) for a non-surgical patient?
The patient had a colonoscopy on 02/16. What deficiency is present in the Operative Report? ehr go introduction to chart deficiencies answers
Query the provider (or mark as "Incomplete - Pending Provider Action"). Rationale: In EHR Go, you cannot correct the chart yourself. You must flag the deficiency so the system sends a notification back to Dr. Lee to co-sign the note. Section C: Clinical Discrepancies (Content Deficiencies) Question 5: Compare the Nursing Flowsheet (08:00 AM) with the Progress Note (08:15 AM). What deficiency exists? Missing Attestation/Signature
Navigating the "Introduction to Chart Deficiencies" module in EHR Go can be daunting for nursing and health information management (HIM) students. This simulation software is designed to mimic real-world electronic health records (EHR), and one of its most challenging exercises involves identifying, auditing, and correcting chart deficiencies. Query the provider (or mark as "Incomplete -
24 hours prior to admission or within 48 hours after admission (depending on the exercise specifics; most EHR Go intro modules use 48 hours post-admission for observation units ). Rationale: Look for the patient's admission date/time in the header. If the H&P was written 72 hours later, it is delinquent.
The Consultation Report from Dr. Lee is present but unauthenticated. What is the action required?