Introduction To Chart Deficiencies Answers — Ehr Go

Discharge Summary (or Discharge Instructions). Rationale: For an inpatient stay exceeding 24 hours, CMS guidelines require a discharge summary within 30 days. In this scenario, the patient was discharged but the provider never finalized the note.

The patient had a colonoscopy on 02/16. What deficiency is present in the Operative Report? ehr go introduction to chart deficiencies answers

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? Discharge Summary (or Discharge Instructions)

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? The patient had a colonoscopy on 02/16