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American College of California Introduction to Chart Deficiencies Worksheet

 

Introduction to Chart Deficiencies – The student will review the data in the patient chart in detail and, by using critical thinking skills, list what is present, deficient, incorrect or incomplete in the patient chart.

Retrieval of Data – You are a Health Information Technician at a large academic hospital. One of the hospital’s attending physicians has asked you to begin the process of compiling data from the hospital’s EHR. She is conducting a study on Acute Coronary Syndromes and has given you specific data to retrieve. Included in the information provided by the physician is a list of 20 names of patients who have been preliminarily enrolled in her study. These patients have recently been discharged from General Hospital after receiving treatment for some form of Acute Coronary Syndrome.