Retrieval of Data (Associate) - AK1010.2

Knowledge Activity: Retrieval of Data (Associate)
Learning objectives
1. Collect and maintain health data
2. Demonstrate documentation in the health record that is complete and accurate
3. Apply data entry skills
Student instructions
1. If you have questions about this activity, please contact your instructor for assistance.
2. You will review the chart of Jean Katz to complete this activity. Your instructor has
provided you with a link to the Retrieval of Data (AS) activity. Click on 2: Launch EHR to
review the patient chart and begin this activity.
3. Refer to the patient chart and any suggested resources to complete this activity.
4. Document your answers directly on this activity document as you complete the activity.
When you are finished, you will save this activity document to your device and upload
this activity document with your answers to your Learning Management System (LMS).
Glossary
Algorithm/protocol: A mapping of rules that explain best practices or recommended
procedures to be followed in specific situations. (Myers, 2006).
ICD code: International Classification of Diseases (ICD) is the standard diagnostic tool for used
both for clinical and health management purposes, as well as for epidemiology. An ICD code is
used to classify and monitor disease and health problems. Example of an ICD-10 code: E21.0
(Primary hyperparathyroidism). (World Health Organization, 2016)
The activity
Review the Acute Coronary Syndromes Algorithm resource document found under Step 1:
Overview & Resources where this activity document was located. This resource is needed to
successfully complete the activity.
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
EHR Go Knowledge Activity: Retrieval of Data (Associate) AK1010.2 1

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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. The first patient on the list is Jean Katz.
Launch and review the EHR of Jean Katz. Using the information in her chart and the resource
mentioned above, answer the following questions.
Questions
1. Ms. Katz has a problem of chest pain documented under the Problems tab. Is an ICD
code included with this problem in her chart? No ICD code listed
2. What priority is Ms. Katz’s problem of chest pain?

a. Active
b. Acute
c. Admitting
d. ACS
3. What other acute problem was Ms. Katz experiencing in addition to her chest pain?
a. Primary hypertension
b. Shortness of breath
c. Hyperlipidemia
d. Osteoarthritis (both hands)
4. Was Ms. Katz admitted as an inpatient to the General Hospital? Where did you locate
this information?
Yes and this information was discovered in the notes
5. Did Ms. Katz receive oxygen while at the hospital? Where did you locate this
information?
Yes she received oxygen and this information is located orders category
supplies/devices
6. What was Ms. Katz’s initial blood pressure? Where did you locate this information?
154/88 located under vitals
7. Was an order for Nitroglycerin entered for Ms. Katz? Where did you locate this
information?
Yes there was an order found this information in orders under scheduled meds

8. If Nitroglycerin was ordered, was the medication administered to Ms. Katz? Where did
you locate this information?
Yes it was administered to her and it was given to her sublingual by the RD Kim
Anderson
9. Review the ACS Algorithm document provided with this activity document. Briefly list
the guidelines, or protocol, for assessment and treatment once a patient has arrived at
the Emergency Room/Department (ER or ED).
Rapid assessment and triage - Obtain vital signs and perform a focused physical exam -
Obtain a 12-lead ECG within 10 minutes of arrival - Administer oxygen if needed - Administer
aspirin if not contraindicated - Administer nitroglycerin if not contraindicated - Administer
morphine if needed for pain relief - Obtain blood samples for cardiac biomarkers - Determine
the need for further testing and treatment based on the patient's risk stratification
10. According to the documentation in Ms. Katz’s chart, indicate whether each guideline
from the protocol in your answer above was met upon her arrival to the ED.
Yes her vitals were taken, she received an ECG, oxygen was administered as well. They
followed all protocols
11. After ED assessment and treatment are completed, what is the next step taken by the
healthcare team to determine the appropriate treatment according to the protocol?
The next stair will be the discharge process. With discharge it is a plan for treatment
after being released and the follow ups needed for the patients care
12. In your opinion, what are some benefits of healthcare professionals providing care
based on nationally approved protocols and guidelines?
Being that they are using protocols is ensures that all patients are handled the same
way and it makes it easier to read their health record should another professional
need to access their file.
Submit your work

Document your answers directly on this activity document as you complete the activity. When
you are finished, save this activity document to your device and upload this activity document
with your answers to your Learning Management System (LMS). If you have any questions
about submitting your work to your LMS, please contact your instructor.
References

CPR & First Aid. (n.d.). Part 9: Acute Coronary Syndromes. Retrieved from
https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-9-acute-
coronary-syndromes/
Myers, T. (2006). The value of care algorithms. Pharmacotherapy, 26(9 Pt 2), 1815-1915.
World Health Organization. (2016). International Statistical Classification of Diseases and Related Health
Problems, 10th Revision. Volume 2. . Retrieved from
http://apps.who.int/classifications/icd10/browse/Content/statichtml/
ICD10Volume2_en_2016.pdf\


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Knowledge Activity: Retrieval of Data (Associate)

EHR Go Knowledge Activity: Retrieval of Data (Associate) AK1010.2 1

2. What priority is Ms. Katz’s problem of chest pain?

EHR Go Knowledge Activity: Retrieval of Data (Associate) AK1010.2 2

Submit your work

EHR Go Knowledge Activity: Retrieval of Data (Associate) AK1010.2 3

EHR Go Knowledge Activity: Retrieval of Data (Associate) AK1010.2 4

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