Big Daddy (7) Flashcards
How does a healthcare policy assure access to health information by authorized users?
It creates a reliable method to verify the identities of users accessing health information.
A patients glucose blood sugar is 400. What is a one-time kind of report?
Ad Hoc
Which clinical information technology enables providers to document patient assessments?
Vitals signs capture
Which is a physician’s clinical informatics assessment?
Vital signs
The nurse receives report that there are new orders to review. Where does the nurse look to verify this information?
The Kardex
Which area of the EHR is used to guide a nurse on the tasks that need to be completed during the shift?
The worklist
Which type of chart uses rectangle, oval & diamonds in both?
Flowchart
On admission, a patient reports several allergies. Where does the nurse confirm the documentation of this information?
In the patient summary tab
Where are POLST (advanced care directives) found on the computer?
Media tab
- Provider wants you to change an order what tab would you look under?
Order summary tab
- When a physician arrives on the unit, a nurse is asked about the fluid status of a patient. Where should the nurse find this information?
The intake & output chart
High pt volume
Nursing flowsheet
MRSA
contact precautions
A Nursing Innovator & medsurg nurse want to capture how many patients were seen in a day of 24 hours, how would they best see this?
Flowsheet
Pts come in complaining of the same S/S
pt demographics
Pt discharge, information planning
History & physical notes about the reason the pt is admitted anyways
Where do you document a patient’s allergy?
History & physical
Suspected dehydration & pt reports dizziness with H/A & decreased u/o
Lab Report
Pt comes to the ED with a bump on the arm that is painful, edematous, & oozing sanguineous fluid. Which data in the pt’s medical record would tell a nurse to implement infection control precautions?
The nursing flow sheet states the wound has increased in edema, redness, & drainage over the last 12 hours
COPD pt planning care
complete health history
A restraint committee has been assembled to oversee the need & proper usage of restraints. It has asked a report to be constructed to allow better tracking of restraint usage & documentation compliance throughout the organization. Which data element would this committee find least useful in this report?
Patient allergy history
Reported falls on the med surg unit as compared to the previous quarter. Which data set informs the decision to review the protocol for falls on the med-surg unit?
The radiology reports of pts with a reported fall on the med-surg unit
Which data in a medical record informs the management of the pt’s condition following a surgical procedure?
Nursing assessment from the prior shift & the doctor’s orders
is a standard person-identifier code that uniquely identifies an individual and permits the correlation process to match the person’s data from a variety of different sources of health providers (e.g., clinics, hospitals, pharmacies, and nursing homes).
A master patient index (MPI)
A patient goes to a clinic’s office complaining of a cough. The physician orders a chest X-ray & sends the patient to the radiology department. The clinic’s admitting department & the radiology office use different information systems. What is used to locate the record in each of these different
systems?
Master patient index
What is data governance?
Defines who can take what action, upon what data, in what situations, using what methods.
When considering the lack of appropriate infrastructure as a factor contributing to challenges in finding and using big data in healthcare, why is a governance structure necessary?
A governance structure creates the balance between privacy and access while complying with state, national, and international ethical and legal requirements.
Refers to the collection of policies, standards, processes, & controls applied to an organization’s data?
Data governance
Which change theory begins with creating urgency?
Kotter’s Models
What is the term for sharing a person’s personal information with other individuals electronically?
Information sharing
What describes an example of opt-in or opt-out choice regarding the disclosure of personal health information?
Your information be sent to another facility
A nurse has a new order for an anti-arrhythmic drug via IV drip. What needs to be done before this medication can be safely administered?
Use the 5 rights of medication administration.
A laboratory manager requested a report of all patients that had a blood glucose greater than 400 mg/dL for the month of July to provide to the corporate office. Which type of report should the nurse informaticists create using information stored in the electronic health record for this one-time request?
Short time report
What is the first thing patients should do to access their health records?
Ask for access to their documents
You are contacted by a confused user because their legend changes on each screen they go into, would you tell them?
The screen symbols change on each screen depending on the activities done
A nurse is entering a verbal medication order & encounters a warning the entry is a duplicate. Which action does the nurse take?
Call MD & verify order & MD enter order remotely
There are different systems for L&D & the hospital, how would you check for orders & medications?
Log out of L&D system and log into the Hospital system
Which tool highlights the areas in which information technology can improve efficiency & support an interdisciplinary healthcare team?
A workflow analysis
Which two statements define healthcare informatics (HI)?
A tool to improve practice & patient care. A field that involves the secure sharing of information.
When developing new clinical workflow, what is one of the first steps that should be taken?
Review old progress & old documents.
Which item describes a basic network code that determines the rules used to create & route packet of data between network devices?
Transmission control protocol/internet protocol (TCP/IP)
The value of the “blank” can only be experienced and appreciated if it is known to its users. There are several challenges to the use of the HIE. One major challenge to embedding HIE in care practice is a lack of awareness about HIE among clinicians. The coordination of care can be enhanced through the use of HIEs by helping nurses understand the root cause of frequent visits, identifying duplicate orders for tests, and maintaining accurate medication lists.
HIE
What are connectivity systems?
They support the integration of data across different organizations
The healthcare organization has a different surgery system that is integrated with the organization’s main EHR. What should this healthcare team do to ensure all information is properly charted?
Chart in the surgical system & the appropriate data will be accessible in the HER.
Unit managers want to be assured nurses are signing completed clinical documentation. What can managers do to determine documentation completion?
Randomly run EHR reports & list noncompliant nurses.
A nurse has a new order to begin antiarrhythmic medication via IV drip. What needs to be done electronically before this medication can be safely administered?
Scan the patient’s armband & the medication
What is role-based access an example of?
Authenticity
What is the first thing patients should do to access their health records?
Use the patient portal email from the healthcare organization to create an account.
Which form allows stored information in an EHR to be instantly searched, retrieved, combined, and reported in different ways?
Text data
Healthcare staff members become overwhelmed when using EHR, & they begin to ignore clinical decision support messages. Why is it important to control the number of warnings in an EHR?
Alert fatigue
Why is it important to control the number of warnings in EHR?
Alert fatigue
What should healthcare staff who use mobile devices to access electronic protected information (ePHI) do to protect devices before they are lost or stolen?
Turn off file sharing
A healthcare facility is changing to a new health information system. Information from the old system needs to be input into the new system. What will the IT department do to complete this task?
Migrate the data
Crusted rash, CDC says that the diagnosis of scabies is by physical examination of skin
Pt with scabies
Provider receives a message with a low BP with a normal HR reading but that’s all it said?
The info cannot help Dr make a clinical decision
Critical step in HCI?
Usability
Tapping badge?
improves documentation time
Data accuracy?
Triangulation
Confirming data accuracy?
Triangulation
Pt engagement benefits
costs decrease, lower readmission rate, improved pt recovery times, increase pt empowerment
