Which of the following clinical system functions allows the nurse to provide more efficient patient care?
Order entry
Which of the following supports the automation of nursing documents?
The use of standardized nursing languaes (SNLs) accepted by the American Nurses Association, The use of interventions such as "turn, cough, and deep breathe" as etermined by the Nursing Interventions Classifications (NIC), The use of nursing diagnoses such as "Alternation of Comfort" as define by the North American Nursing Diagnosis Association (NANDA)
The client registration system is also known as which of the following?
Admission/Discharge/Transfer System
Which of the following describes home care information system?
Uses monitoring technology which, when integrated into information system, provides a way to care for the targer population
Which of the following depicts the nationwide initiative to prevent medication errors?
Adverse events are reported through MedWatch, Federal Drug Administation (FDA) rejects applications for new drug names that are similar to older drug names, Advocating clinical decision support (CDS) systems, The Institue for Safe Medication Practices publishes a consumer newsletter on medicaiton errors
Which type of software has been developed by the consumer to meet specific needs usually because no suitable commercial package is available?
Home grown
A nursing information system identify variances to the anticipated outcomes as they are charted and provide aggregate variance data for analysis by the providers. This information can be used to line tune and improve ____________ thereby contributing to improved client outcomes.
Critical Pathways
___________ can be used to fine tune and improve critical pathways thereby contributing to improved client outcomes.
Variances
The following answers are standardized languages used across the discipline of nursing that allow nurses to describe nursing problems, treatments, and outcomes in a manner that is understood by all nurses except which?
HIS
Which of the following are true about using automated pharmacy systems?
An automated system pulls in laboratory results and clinet information from the HIS more quickly to identify allergy and interaction problems, Individual client data is integrated and provides the pharmacist with up-to-date information
Which of the following can be used with CISs to allow information entry and retrieval at the point of care or wherever it is needed by the health care professional?
Mobile and wireless technology
Which of these is an example of a decision support system (DSS)?
A system used by physicians to provide suggestions for diagnostic tests according to selected admitting diagnoses
Which of the following statements suggests that the use of mobile devices in the health care setting can enhance patient care?
Personal access to patient's home address
A nursing information system is considered to be effective if which of the following goals are accomplished?
Supports nursing and enhances practices
Information system interact to provide checks and alerts throughout the medication ordering and administration process. Which of the following are steps in this process in which bar codes are utilized for medication ordering and administration?
Bar code on the medicaiton label is scanned, Bar code on patient's identification bracelet is scanned, Bar code on nurse's identification badge is scanned
Which of the following can identify the client in all information systems across the organization?
Client identification code
_____________ and wireless technology can be used with CISs to allow information entry and retrieval at the point of care or wherever it is needed by the health care professional
Mobile
Which of these is an advantage of implementing a computerized order entry system?
Each department is notified simultaneously as orders are processed through the system
____________ are large, computerized database management systems that support several types of activities that may include provider order entry, result retrieval, documentation, and decision support across distributed locations.
Clinical Information Systems
___________ systems use clinical information to generate charges for care.
Coding
____________ aid in and strengthen the selection of viable options using the information of an organization or a field to facilitate decision making and overall efficiency.
Decision Support Systems
Which of the following is characteristic of an automated radiology information system (RIS)?
As each test is ordered, the user is prompted to answer questions such as the purpose of the test
Which of the following are considered benefits of electronic prescriptions?
Eliminates phone calls for refills, Reviews clients drug histories before purchasing, Provides reminders for prescriptions, Alerts providers about drug reactions
Clinical Information system (CISs) can have a positive impact on which of the following?
Pharmacy, Raiology, Laboratory department, Nursing department
Which of the following systems supports the use and documentation of nursing processes and activities, and provides tools for managing the delivery of nursing care?
Nursing Information System
Which statement indicates the nurse is correctly documenting according to a critical pathway?
Variances are identified if client outcomes are not as anticipated
Which of the following is the best example of a monitoring system?
A temperatire probe is connected to the pulmonary artery catheter to continuously monitor core temperature
Medication errors have been on the rise over the past decade. A national initiative to minimize or eliminate the errors can be supported through which of the following responses?
The bar codes of the nurse, client's identification bracelet, and prescription medication are scanned and compared
For many years the EMR applied to a single encounter with no ability or very limited ability, to carry information from one visit to another within a care delivery system. That situation has changed. it is now possible to bring information forward from prior visits within the organization or delivery system. Which of the following answers are basic components of the EMR system?
Clinical messaging and e-mail, Results reporting, Decision support, Clinical documentation, Order entry
Which of the following are major impediments to the development of an electronic health record (EHR)?
Development of an electronic infrastructure, Confidentiality, Cost, Lack of a common vocabulary
___________ would permit the uniform capture of data required to build a longitudinal record comprised of integrated information systems from multiple vendors.
Data Exchange Standards
Personal health record (PHR) security issues relate to HIPAA and physical security of data. HIPAA only covers PHPs provided by covered entities such as health plans, health care clearinghouses, and provides. No government coverage exists for other sites unless it is at the state level. To avoid these types of breaches, the American Health Information Community's consumer empowerment working group made a recommendation. Which of the following was recommended for PHRs in order to avoid breaches?
A PHP certification process
Consumers are the primary source of information about their health history and medications. The patient-carried record (PCR) addresses this. Which of the following are potential problems associated with the PCR?
Loss of the record, Privacy, Liability, Legibility
While most hospitals have some level of automation, few have attained a fully electronic environment. Health care Information and Management Systems Society (HISS) analytics created an EMR adoption model that identifies eight levels of EMR capabilities. Your hospital has been designated as a Stage 3 facility. Which of the following is accurate about an organization at Stage 3 level?
Basic clinical documentation is required
The computer-based patient record (CPR) is a comprehensive lifetime record that includes all information from al specialties. Most of the data included in the CPR is which of the following?
Structured data
A hospital client sees the nurse documenting information into the computer. She asks the nurse why the computer is better than the "old patient chart like hospitals have always used." Which of the following points would be accurate to say about an electronic medical record?
It captures the information needed for billing purposes, It is more secure than a paper record, More than one person can access the record at any given time, The record is available when and where needed, Data are in real-time, as things happen
Electronic medical record (EMR) result reporting and data repository components include unstructured data. Which of the following are examples of unstructured data?
History and physical, Consultation findings, A social services text report
Which of the following statements is true about the benefits of the electronic health record (EHR)?
Little scientific evidence now exists on what benefits are actually delivered
The goals of implementing the EHR in all health care systems are fraught with a number of roadblocks? The largest barrier facing most institutions is which of the following?
Cost
The electronic health record (EHR) has the potential to integrate all pertinent patient information into one record. It also has potential to improve the quality of health information, patient safety, and productivity, contain costs, support research, decrease wait time for treatment and contribute to the body of the health care knowledge. Which of the following are reasons why traditional paper records on clients no longer meet the needs of today's health care industry?
Paper records are episode-oriented with a separate record for each client visit, Key information may be lost from one episode to the next jeopardixing patient safety, Only one person can access a paper record at any given time, Different versions of the same information may be stored in several places, Paper records cannot incorpoate disagnostic studies that include images and sounds
Which of the following topics must be addressed when giving a presenation to physicians on the benefits of the electronic medical record (EMR)?
Easier access to previous documented encounters, Facilitation of clinical pathways, Chart access speed, Reduced liabilities through accurate documentation
Which of the following statements about meaningful use is correct?
Meaningful use will provide invaluable inforamtion that will improve patient outcomes and population health changing many current practices as we transform our health care delivery system
Unlike other health records the ___________ is patient-centered, presenting a more-balanced view of an individual's health history.
Personal Health Record
The relationship between meaningful use and the adoption of the EHR in hospitals, physician offices, nd other settings is best described as which of the following?
The meaningful use requirement is achieved with the adoption and use of the EHR system as part of the daily routine
The EHR offers benefits to nurses, physicians, and other health care providers, the health care enterprise, and most importantly, the consumer. Much must be done before the benefits associated with the EHR can be realized. Which of the following is one action that has been proposed by experts?
Government intervention should promote information exchange among software vendors and health care systems
Healthcare information and Management Systems Society (HIMSS) has defined and described the term electronic. Personal Health Record (ePHR). Which of the following are included in the HIMSS definition and description?
Universally accessible, Owned and managed by the individal (or legal proxy), Common data set of electronic health information, Lifelong tool for managing relevant health information
Which of the following best described the electronic medical record (EMR)?
Legal record created in hospitals
The mere implementation of an electronic medical record (EMR) does not guarantee that benefits will be achieved. Which of the following can affect data integrity?
System failure
Information in the electronic health record (EMR) may be owned by the patient or stakeholder. Which of the following about the EHR is different than the electronic medical record (EMR)?
Clients may append information if desired
The Bush administration called for the adoption of the electronic health record (EHR) by 2014 as a means to help transform U.S. health care. Who owns the individual client record when an EHR is used?
Ownership is unclear
Which of the following are considered impediments to a fully functional electronic health record (EHR) system?
Development of an electronic infrastructure, Cost, Privacy
Which of the following are found with the electronic health record (EHR) but are not found with the computer-based patient record (CPR)?
Evidence-based decision support, Assists with the world of planning and delivering evidence-based care, Quality management, Public health disease surveillance and reporting, Comprehensive lifetime recird that includes all information from all specialties
An emerging technology related to electronic health record (EHR) progress is the use of the personal health record (PHR). PHRs store client information that will eventually contribute to the development of a comprehensive, longitudinal record. Which of the following are found in a PHR but not found in the EHR?
Periodic risk assessment survey results, Herbal supplements, Decision support, Health status parameters such as exercise
Which of the following is a major component of the computer-based patient record (CPR)?
Support for links to local or remote information resources
The U.S. Department of Health and Human Services indicated that the __________ is a digital collection of patient's medical history.
EHR (Electronic Health Record)
The computer-based patient record (CPR) is a comprehensive lifetime record that includes all information from all specialties. The Institute of Medicine (IOM) identified major components of the CPR that are considered to be the "gold standard" attributes. Which of the following are CPR components?
Provides a patient problem list