Understanding the Patient's Chart
This folder includes clinical Q&A on a patient case involving cerebral palsy, medical abbreviations, functional assessments, and gastroenteritis—useful for students in nursing, health science, or medical terminology courses.
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T h e activity
Review the patient's chart as directed below to answer the following questions.
Q u e s t i o n s
Review the Admission H&P note on the Notes tab in Neveah's chart.
On the Notes tab, in the note titled Admission H&P, the "Chief Complaint" is one or two
sentences listing either the patient's current symptoms or reason for seeking care. I t is
sometimes in the patient's own words, enclosed in quotes.
1. What does H&P stand for?
- H&P stands for History and Physical Exam
2- in Neveah's Admission H&P. what is the chief complaint?
- acute symptoms of abdominal pain, fever, loose/mucousy diarrhea, loss of appetite
dehydration
EHR Go Knowledge Activity: EHR Documentation Standards AK1OO3.8
Archetype Innovations LLC ©2022 1
Review the patient's chart as directed below to answer the following questions.
Q u e s t i o n s
Review the Admission H&P note on the Notes tab in Neveah's chart.
On the Notes tab, in the note titled Admission H&P, the "Chief Complaint" is one or two
sentences listing either the patient's current symptoms or reason for seeking care. I t is
sometimes in the patient's own words, enclosed in quotes.
1. What does H&P stand for?
- H&P stands for History and Physical Exam
2- in Neveah's Admission H&P. what is the chief complaint?
- acute symptoms of abdominal pain, fever, loose/mucousy diarrhea, loss of appetite
dehydration
EHR Go Knowledge Activity: EHR Documentation Standards AK1OO3.8
Archetype Innovations LLC ©2022 1
3. Neve ah has a history of Dyskinetic Cerebral Palsy. What is Cerebral Palsy? (Hint: Refer to
the resource titled 'Cerebral Palsy Overview" found under 1 : Overview & Resources
along with this activity document.)
Cerebral palsy is a static neurologic condition that affects body movement and
muscle coordination
4- What does t h e abbreviation ETOH stand for? (Hint: Refer to the resource titled 'Medical
Abbreviations_Taber’s Medical Dictionary found under 1 : Overview & Resources along
with this activity document.)
ETOH stands for ethyl alcohol
5. What does t h e a bb reviatio n NKA stand for?
NKA stands for n o known aIle rgi es
6- Where else is NKA listed in this patient's chart?
it is listed under Alerts
7. What does t h e a bb reviatio n HTN sta n d fo r?
HTN stands for hypertension
8- In the Functional Status section of the note it states, "Mother reports patient assessed at
G MFCS Level III - walks with adaptive equipment assistance." What does GM FCS stand
for and what is the test used for?
Gross Motor Function Classification System
9. What is the difference between the Review o f Systems and the Physical Examination
sections of the H&P written by the physician?
main difference between the review of systems and physical examination is that
review of systems is subjective and physical examination is objective
10. Neveah is ultimately admitted for gastroenteritis. What is gastroenteritis?
Gastroenteritis (stomach flu) caused by a bacterial o r viral t u m m y bug. (inflammation
of the stomach and intestines)
Review the Nursing Admission Assessment note o n the Notestab of Neveah's chart t o answer
the following questions.
11. Under the section, Personal Property and Assistive Devices, it is documented: "Kept by
parent clothing wearable for DC." In this note. DC is intended to refer to discharge.
According to Taber's Online Medico) Dictionary' DC stands for Doctor of Chiropractic or
direct current. Based o n this information, do you think DC is a goodor safe abbreviation
t o use? Why or why not?
no. DC is not a safe abbreviation to use because it has so many meanings such as
discontinue, direct cur re nt, or doctor of chiropractic
12. Under Medications. Immunizations, Allergies, the nurse writes "Depakote sprinkles:
SOmg PO BID 0900, 2100." What does "PO BID" mean? (Hint: Refer to the resource titled
Medical Abbreviations Taber's Medical Dictionary found under 1 : Overview & Resources
along with this activity document.)
EHRGc Knowledge Activity: EHR Documentation Standards AK1003.E
Archetype Innovations LLC ©2022 2
the resource titled 'Cerebral Palsy Overview" found under 1 : Overview & Resources
along with this activity document.)
Cerebral palsy is a static neurologic condition that affects body movement and
muscle coordination
4- What does t h e abbreviation ETOH stand for? (Hint: Refer to the resource titled 'Medical
Abbreviations_Taber’s Medical Dictionary found under 1 : Overview & Resources along
with this activity document.)
ETOH stands for ethyl alcohol
5. What does t h e a bb reviatio n NKA stand for?
NKA stands for n o known aIle rgi es
6- Where else is NKA listed in this patient's chart?
it is listed under Alerts
7. What does t h e a bb reviatio n HTN sta n d fo r?
HTN stands for hypertension
8- In the Functional Status section of the note it states, "Mother reports patient assessed at
G MFCS Level III - walks with adaptive equipment assistance." What does GM FCS stand
for and what is the test used for?
Gross Motor Function Classification System
9. What is the difference between the Review o f Systems and the Physical Examination
sections of the H&P written by the physician?
main difference between the review of systems and physical examination is that
review of systems is subjective and physical examination is objective
10. Neveah is ultimately admitted for gastroenteritis. What is gastroenteritis?
Gastroenteritis (stomach flu) caused by a bacterial o r viral t u m m y bug. (inflammation
of the stomach and intestines)
Review the Nursing Admission Assessment note o n the Notestab of Neveah's chart t o answer
the following questions.
11. Under the section, Personal Property and Assistive Devices, it is documented: "Kept by
parent clothing wearable for DC." In this note. DC is intended to refer to discharge.
According to Taber's Online Medico) Dictionary' DC stands for Doctor of Chiropractic or
direct current. Based o n this information, do you think DC is a goodor safe abbreviation
t o use? Why or why not?
no. DC is not a safe abbreviation to use because it has so many meanings such as
discontinue, direct cur re nt, or doctor of chiropractic
12. Under Medications. Immunizations, Allergies, the nurse writes "Depakote sprinkles:
SOmg PO BID 0900, 2100." What does "PO BID" mean? (Hint: Refer to the resource titled
Medical Abbreviations Taber's Medical Dictionary found under 1 : Overview & Resources
along with this activity document.)
EHRGc Knowledge Activity: EHR Documentation Standards AK1003.E
Archetype Innovations LLC ©2022 2
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