Ch. 20 Informatics Flashcards
A nurse is preparing information for a change‑of‑shift report. Which of the following information should the nurse include in the report?
A. Input and output for the shift
B. Blood pressure from the previous day
C. Bone scan scheduled for today
D. Medication routine from the medication
administration record
C. CORRECT: The bone scan is important because the nurse might have to modify the client’s care to accommodate leaving the unit
A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.)
A. A single electronic records password is
provided for nurses on the same unit.
B. Family members should provide a code prior to receiving client health information.
C. Communication of client information
can occur at the nurses’ station.
D. A client can request a copy of their medical record.
E. A nurse can photocopy a client’s medical
record for transfer to another facility.
B. CORRECT: The HIPAA Privacy Rule states that information should only be disclosed to authorized individuals to whom the client has provided consent. Many hospitals use a code system to identify those individuals and should only provide information if the individual can give the code.
C. CORRECT: The HIPAA Privacy Rule states that communication about a client should only take place in a private setting
where unauthorized individuals cannot overhear it. A unit nurses’ station is considered a private and secure location.
D. CORRECT: The HIPAA Privacy Rule states that clients have a right to read and obtain a copy of their medical record.
E. CORRECT: The HIPAA Privacy Rule states that nurses can only photocopy a client’s medical record if it is to be used for transfer to another facility or provider
A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client’s record? (Select all that apply.)
A. Cover errors with correction fluid, and
write in the correct information.
B. Put the date and time on all entries.
C. Document objective data, leaving out opinions.
D. Use as many abbreviations as possible.
E. Wait until the end of the shift to document
B. CORRECT: The day and time confirm the recording of the correct sequence of events.
C. CORRECT: Documentation must be factual, descriptive, and objective, without opinions or criticism
A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply).
A. Medication error
B. Needlesticks
C. Conflict with provider and nursing staff
D. Omission of prescription
E. Missed specimen collection of a prescribed laboratory test
A. CORRECT: Complete an incident report regarding a medication error.
B. CORRECT: Complete an incident report regarding a needlestick.
C. Report a conflict with a provider and nursing staff to the charge nurse or nurse manager.
D. CORRECT: Complete an incident report following an omission of a prescription
A nurse is receiving a provider’s prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.)
A. Repeat the details of the prescription back to the provider.
B. Have another nurse listen to the telephone prescription.
C. Obtain the provider’s signature on the prescription within 24 hr.
D. Decline the verbal prescription because it is not an emergency situation.
E. Tell the charge nurse that the provider has prescribed morphine by telephone
A. CORRECT: The nurse should repeat the medication’s name, dosage, time or interval, route, and any other pertinent information back to the provider and receive and document confirmation.
B. CORRECT: Having another nurse listen to the telephone prescription is a safety precaution that helps prevent medication errors due to miscommunication.
C. CORRECT: The provider must sign the prescription within the time frame the facility specifies in its policies (generally 24 hr.
What is health literacy?
The ability to read, write, and understand health-related information.
What in Informatics?
The use of information and technology to communicate, manage knowledge, mitigate errors, and support decision-making.
What are electronic monitoring devices?
A form of telehealth medicine that assists in tracking patient information and facilitates immediate transfer of information.
Implantable devices.
What does HIPPA stand for?
Health Insurance Portability & Accountability Act
What is telehealth?
Using telecommunications and video conferencing to provide patient care outside of the typical clinical setting.
A home health care nurse is using the steps of the SDLC, to design a new system for home health care documentation. The nurse analyzes the old system and develops plans for the new system. What is the next step of the nurse in this process?
A) Test
B) Design
C) Implement
D) Evaluate
b. The SDLC requires focus in the areas of Analyze and Plan, Design and Build, Test, Train, Implement, Maintain, and Evaluate. After analyzing and planning the new system, the nurse would move on to the design step in which the basic design of the new system is developed. The nurse would then test the system, train employees, and implement, maintain, and evaluate the new system in that order.
After instituting a new system for recording patient data, a nurse evaluates the “usability” of the system. Which actions by the nurse BEST reflect this goal? Select all that apply.
A) The nurse checks that the screens are formatted to allow for ease of data entry.
B) The nurse reorders the screen sequencing to maximize effective use of the system.
C) The nurse ensures that the computers can be used by specified users effectively.
D) The nurse checks that the system is intuitive, and supportive of nurses.
E) The nurse improves end-user skills and satisfaction with the new system.
F) The nurse ensures patient data is able to be shared across health care systems
a, c, d. Usability refers to the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use. Checking that screens are formatted to allow ease of data entry, ensuring that computers can be used by specified users effectively, and checking that the system is intuitive and supportive of nurses are all tasks related to the “usability” of the system. Reordering screen sequencing to maximize use and improving end-user skills and satisfaction with the new system refers to optimization. The ability to share patient data across health care systems is termed interoperability.
A nurse is using informatics technology to decide which patients may be at risk for readmission. What is the term for this type of analytic?
A) Data visualization
B) Predictive analytics
C) Big data
D) Data recall
b. Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. In health care, this is used by organizations to attempt to identify patients who are at risk for readmission so case managers can intervene. Data visualization is the presentation of data in a pictorial or graphical format for analysis. Big data comprises the accumulation of health care–related data from various sources, combined with new technologies that allow for the transformation of data to information, to knowledge, and ultimately to wisdom. Data recall is not a technical term for analytics.
Population health addresses the health status and health issues of aggregate populations and addresses ways in which resources may be allocated to address these concerns. What is the driving force behind the use by health corporations of analytics and big data to support population health?
A) The transition from fee-for-service models to value-based payment models
B) A growing older population with more complicated health needs
C) The overcrowding and understaffing of hospitals
D) The shortage of health care professionals, particularly nurses
a. Information technology is a part of the core infrastructure on which population health can be assessed and addressed. As organizations transition from the traditional fee-for-service model to value-based payment models (including ACOs), data, information, and knowledge about populations rather than individual patients will be required. A growing older population with more complicated health needs, the overcrowding and understaffing of hospitals, and the shortage of health care professionals, particularly nurses, may be affected by population health assessment, but are not the driving force for the development of this technology.
Nurses incorporate telecare in patient care plans. Which services are MOST representative of this technologic advance? Select all that apply.
A) Diagnostic testing
B) Easy access to specialists
C) Health and fitness apps
D) Early warning and detection technologies
E) Digital medication reminder systems
F) Monitoring of progress following treatment
b, c, d. Telecare generally refers to technology that allows consumers to stay safe and independent in their own homes. It may include consumer-oriented health and fitness apps, sensors and tools that connect consumers with family members or other caregivers, exercise tracking tools, digital medication reminder systems, and early warning and detection technologies. Telemedicine involves the use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians or nurse practitioners. Examples include conducting diagnostic tests, monitoring a patient’s progress after treatment or therapy, and facilitating access to specialists that are not located in the same place as the patient.
