Look closely at the bottom of notes for text like “Draft” or “Unsigned.” This is an immediate indicator of a deficiency.

Missing allergies or medication histories can cause adverse events.

💡 Example from actual student work: In one deficiency analysis, students identified and lack of legibility as two chart deficiencies that could compromise patient care – inaccurate documentation leading to misunderstandings and illegible handwriting causing medication errors.

Often, the H&P is in the system, but the provider failed to electronically sign it.

Which document shows evidence of cloning?

Organizations like The Joint Commission audit chart completion rates during accreditation surveys. Step-by-Step Guide to EHR Go Chart Deficiencies Answers

Every order, verbal instruction, progress note, and discharge summary requires authentication. In EHR Go, look at the bottom of the documents. If an order status reads "Unsigned," "Draft," or "Pending Authentication," it is deficient. Note the specific name of the provider who ordered the intervention, as your assignment will likely ask you to whom the deficiency should be assigned. 4. Review the Discharge Summary

If your assigned patient underwent surgery, an operative note must be dictated immediately following the procedure. Look at the surgical nursing notes to find the time the operation ended. Then, check the "Notes" tab for the surgeon's official report. A brief immediate post-op note is required if the full report is delayed. Missing either of these constitutes a clear chart error. 3. Audit for Authentication and Signatures

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.

On a system level, unresolved chart deficiencies can: