Please follow this link to access Jacy Redbird's EHR Go chart and complete the assignment.

https://web21.ehrgo.com/rd/?courseActivityId=32987

Questions

1. Use the following information to assist you in completing the form below after reviewing Jacy Sky Redbird's chart.
   • If the item is present, check the box in front of the item to indicate that the item is correctly documented and all relevant information is spelled correctly.

Identify what items are present, deficient, incorrect or incomplete in Jacy Sky Redbird's chart.

• Deficient: If the item is missing from the chart. The review of the health record to ensure hospital policy for document and legislated standards are met and to determine the adequacy of entries documenting the quality of care.
• Incorrect: Incorrect spelling, dates, wrong patient name, DOB, age or sex. The data or what was entered does not match the rest of the chart contents.
• Incomplete: Information is missing from the note, order or part of the chart.

1. 1. Place an'X' in the applicable box indicating what you could determine based on a thorough review of the entire chart. Use the 'Comments' sections as needed. Add any comments in red.

2. To add an "X" in box place cursor over box, click once. To remove click again.

Overview	Allergies identified or 'No known Allergies' identified Deficient Incorrect Incomplete Comments:
Data Elements	Patient name Incorrect Incomplete Hospital ID # (aka: MR#) identified: Deficient Incorrect Admission date identified Deficient Incorrect Other:
Physician Discharge Summary	Written Deficient Incorrect Incomplete Signed Deficient Incorrect Incomplete Final Diagnosis Deficient Incorrect Incomplete Principal operation or procedure Deficient Incorrect Incomplete Not Applicable (N/A) Admitting Diagnosis Deficient Incorrect Incomplete Summary of hospital course Deficient Incorrect Incomplete Discharge and aftercare instruction Deficient Incorrect Incomplete Condition of patient at discharge Deficient Incorrect Incomplete Disposition of patient Deficient Incorrect Incomplete Comments:
Physician History and Physical	Dr. _________________ Report written Deficient Incorrect Incomplete Comments:
Consultation note/report	N/A Dr. _________________ Report written Deficient Incorrect Incomplete Comments:
Consent for procedure and treatment	N/A Signed by patient or representative Incorrect Incomplete Signed by physician Incorrect Incomplete Comments:
Operative/ Surgical report	Not Applicable Dr. _________________ Pre-op/Post-op diagnosis Deficient Incorrect Incomplete Anesthesia administered Deficient Incorrect Incomplete Details of procedure Deficient Incorrect Incomplete Findings Deficient Incorrect Incomplete Comments:
Pathology report/results	Not Applicable Specimen:_______________________ Comments:
Radiology report/results	Not Applicable Type of exam: ___________________________________ Reason for exam documented: Incorrect Incomplete

B. Complete the chart element checklist on the last page, indicating whether the provided requirement is complete, incomplete, deficientor not applicable (N/A)in Jacy Redbird's EHR.Be sure to review the entire EHR. An item should be considered:

• Complete:if the item is in the EHR and note is not deficient.
• Incomplete:if the item is in the EHR but information is missing from the note.
• Deficient:if the item is missing from the chart (i.e. the item should be documented in the EHR but you are unable to locate it) or is not authenticated.
• Not Applicable (N/A):if the specific element is not needed in this patient's EHR.

If the requirement is not complete, indicate why the item is incomplete, deficient or N/A in the comments section.

Documentation Requirement	Status (Complete, Incomplete, Deficient or NA)	Comments, if applicable
Notes tab
Discharge Summary
History and Physical
Consent for procedure and treatment
Operative/surgical report

At the end of the activity, summarize why and/or how this chart is deficient.

1. Explain why and/or how this chart is deficient. Write your summary here.