Identify Errors in the Record by Jen Brown

Instructions

jenniferwilliams122 — 2025-01-16 15:27:43 UTC

Review the patient record that you provided in your initial post.

Review the document for errors and post your findings for just your document under your assigned group number.

Your assigned groups are as follows:

Adam, Kayla, Elizabeth H, Lauren
Jamie, Kristina, Jade B, Elizabeth J
Kyle, Donna, Shelly

See assignment details posted in myNeosho.

Be specific and detailed
Reference relevant medical documentation standards

The final part of your project will be working with your group to identify all of the errors from the reports posted in Part 2 of your Padlet for your forum discussion post.

jenniferwilliams122 — 2025-03-11 21:03:29 UTC

The attached is a summary of your patient and the reports that will need evaluated (from part 2)

Physician's Orders Report

2026-03-22 20:41:16 UTC

Physical Examination Findings omits "uncomfortable" under general and "clear of rashes" under skin.

The differential diagnosis is written out different on the AI form than on the original form, but basically says the same thing listed out.

Medications are listed on the AI report, but says none on the original form, due to an allergic reaction to levothyroxine.

Overall, there is more information on the AI report than the original report.

Operative Report

2026-03-23 00:51:35 UTC

Report does not does not state that a "timeout" was done to verify site of surgery. Also does not state the there are any allergies. It states that the patient was given local anesthetic, was this performed in the office or in the OR?

Patient Health Record Part 2-Simulated Patient Record

kaylaakers — 2026-03-23 19:56:59 UTC

A.I. Generated: Chat GPT

On the notes the patient's information needs to be added and organized better. Other than that, the layout of the A.I .is pretty on point. I did also notice that the flow record (vitals & assessments) the layout is a little confusing to read it could be organized better. Overall, there is a lot of information laid out on the A.I. more than the original reports itself. I am not sure if that would be too much for a professional job or if unnecessary information is added.

jadebrown15 — 2026-03-23 21:08:56 UTC

A.I Chat GPT. Discharge Summary report failed to have 3 categories that are needed. It is the reason for hospitalization, findings for lab results and imaging, and procedures and treatment given. It is not very well organized as well.

History and Physical Examination (H&P)

2026-03-24 00:47:19 UTC

The AI report for the history and physical examination (H&P), in comparison to the original documentation, is more comprehensive and follows a standardized format (SOAP) that provides a clearer picture as to the reason for the visit, current state of the patient, and treatment plan. The History of Present Illness portion does a good job telling a story, so to speak, of the circumstances concerning the patient’s condition. It does, however, repeat some of the same information, such as patient symptoms. The Social History section also repeats information, mentioning again the recent yard work, which is not necessary. The Review of Systems in the AI report was not included in the original documentation, so the AI generator must have recycled the information from the physical exam and/or chief complaint. Information obtained from the physical exam should not be used for the review of systems as this section is based on the subjective reports by the patient themself. The AI report does acknowledge that some sections did not have any applicable information that would normally be included in an H&P. Some sections, such as Allergies, accurately pulled information from other areas and sorted it correctly. Aside from minor changes that do not really affect the report’s integrity, the AI documentation is pretty solid.

Donna Lanham

2026-03-24 03:37:31 UTC

Emergency Report PDF Filler

It was rather easy just filling out the form. My problem was finding a form that would allow me to fill it out without the most important pieces of information. Name, date and time is critical for emergency room reports to provide a legal time line. It provides liability protection and safety management