Most activities require you to categorize items as Complete, Incomplete, Deficient, or N/A. Requirement Common Status Findings/Comments Overview Allergies Incomplete
Often documented in "Alerts" or "Nursing Notes" instead of the dedicated Overview tab. Advance Directive Deficient
Frequently missing entirely or located in the "Nursing Note" tab instead of "Overview". Principal Diagnosis Complete
Usually found within the History & Physical (H/P) under the "Notes" tab. Orders Admit/Discharge Deficient
Common errors include missing physician signatures or missing discharge orders. Notes Consent Deficient Often missing from the chart entirely. H/P & Discharge Incomplete ehr go introduction to chart deficiencies answers
May be present but missing vital signatures or specific diagnoses. Key Definitions for Your Report
To complete the assignment correctly, use these definitions to justify your findings:
Complete: The item is in the EHR and documented in the correct location/tab.
Incomplete: The information exists but is in the wrong location (e.g., allergies listed in a note but not the summary tab). Most activities require you to categorize items as
Deficient: The information is completely missing from the chart.
Incorrect: Data is present but contains wrong dates, names, or misspellings. Why These Deficiencies Matter
Your report should explain the impact of these errors on patient care: Chart Deficiencies | EHR Go
The Question: "Which document in the chart lacks an authentication?" How to spot it: Look for terms like "Dictated by," "Addendum," or "Incomplete." In EHR Go, if an attending physician’s name appears without a timestamped e-signature or "Verified" stamp, it is a deficiency. The Answer: Usually the Discharge Summary or Operative Report dated the day of discharge without a signature in the attestation field. Access the patient chart via the deficiency queue
The Situation: The deficiency is listed under "Dictation." The Problem: A provider has dictated notes verbally. The transcriptionist has typed it, but the physician has not reviewed the typed text to ensure it matches their dictation. Until they sign it, the record is incomplete.
How to Fix It:
EHR Go considers any order that was "cosigned" more than 2 minutes after the nurse entered it as a potential deficiency if the doctor was present. Actually, the strict rule is: Verbal orders signed > 24 hours later are deficient.