Information Life-Cycle: Sharing and Storing Data (EHR)

Question 1

Many resources use the Data-Information-Knowledge-Wisdom framework to understand nursing ___.

Answer 1

informatics

Question 2

The smallest component where details describe the patient and their environment with little interpretation.

Answer 2

Data

Question 3

Raw facts and figures.

Answer 3

Data

Question 4

On its own is meaningless.

Answer 4

Data

Question 5

Has not been interpreted or processed into meaningful information. Examples: BP 100/50, Pulse 120 BPM (beats per minute).

Answer 5

Data

Question 6

Organized data put into context.

Answer 6

Information

Question 7

Data that has been organized, interpreted and structured is meaningful ___. Example of ___: after surgery, patient’s vital signs BP 110/50, Pulse 120 BPM are significantly altered from patient’s normal vitals (BP 132/ 70, P 72 BPM) which were assessed prior to surgery.

Answer 7

information x2

Question 8

True or false: a nurse puts data into organized information.

Answer 8

True

Question 9

Ensure that the right resources are available to health care professionals so that they can provide safe, efficient, quality care.

Answer 9

Information management systems

Question 10

These resources include clinical guidelines, standards of practice, policy and procedure manuals, research findings, drug databases, best practice guidelines and community resources.

Answer 10

Information management systems

Question 11

Provides access to the most current version of information management systems using intranet and electronic communities.

Answer 11

Information technology

Question 12

Good information ___ also eliminates useless redundant data.

Answer 12

management

Question 13

The science and art of turning data into information.

Answer 13

Informatics

Question 14

Provides tools for nurses to process manage and analyze that data.

Answer 14

Informatics

Question 15

Provides value to nursing knowledge and improves the public image by supporting a knowledge-based identity for nursing.

Answer 15

Informatics

Question 16

The ability to recognize when information is needed as well as the skill to find, evaluate, and use that information effectively.

Answer 16

Information literacy

Question 17

Information that has been processed so that meaningful relationships are identified.

Answer 17

Knowledge

Question 18

Influenced by nursing and scientific theories and assumptions.

Answer 18

Knowledge

Question 19

The full understanding and use of information.

Answer 19

Knowledge

Question 20

When information is processed so that relationships are identified it becomes ___. An example of ___: a nurse recognizes that the surgical patient’s changing vital signs, dropping BP indicate hypovolemic shock.

Answer 20

knowledge x2

Question 21

Knowledge ___ is the more advanced use of information.

Answer 21

management

Question 22

Knowledge ___ is the creation of systems that enable health care organizations to tap into the knowledge, experience, and creativity of their staff to improve their performance. This knowledge includes both professional ___-based knowledge and personal knowledge that each nurse possesses.

Answer 22

management

evidence

Question 23

The appropriate use of knowledge to manage and solve human problems.

Answer 23

Wisdom

Question 24

Implies a form of ethics or knowing why certain things or procedures should or should not be implemented in healthcare practice.

Answer 24

Wisdom

Question 25

Clinical judgment integrating intuition, emotions, and the senses.

Answer 25

Wisdom

Question 26

The ability to make sound judgments based on knowledge and the use of information.

Answer 26

Wisdom

Question 27

The ability to appropriately apply knowledge to the management and solution of problems.

Answer 27

Wisdom

Question 28

An example of ___: the nurse responds appropriately to the data (vital signs) that has collected and uses clinical knowledge to initiate appropriate nursing interventions (maintain intravenous) and prevent or manage impending hypovolemic shock. Nurses use ___ to safely manage patient care.

Answer 28

wisdom x2

Question 29

Occurs when knowledge is used appropriately to manage and solve problems.

Answer 29

Wisdom

Question 30

Involves the human part of processing data and using information and knowledge.

Answer 30

Wisdom

Question 31

Nurses use ___ thinking, the skills, and clinical experience they have to make decisions regarding the care they provide to their patients.

Answer 31

critical

Question 32

Basic identifying data such a patient name, address, date of birth, next of kin, occupation, name of employer, extended health care coverage. Consents for treatment and advance directives can also be a part of this data.

Answer 32

Administrative data

Question 33

Collected and maintained by health care providers and includes data related to the patient’s health, treatment, and plan of care.

Answer 33

Clinical data

Question 34

The patient’s past medical history, the doctor’s orders and progress notes, laboratory results, nurses’ notes, medication administration record, consultation reports, discharge summary, and the patient’s physical exam are all part of this data.

Answer 34

Clinical data

Question 35

True or false: many disciplines contribute to the collection of clinical data including nurses, doctors, pharmacists, social workers, physiotherapists, occupational therapists, radiologists, and such.

Answer 35

True

Question 36

Health care organizations and healthcare providers have the responsibility to ensure that data in the health record is accurate, ___, and recorded in a ___ fashion.

Answer 36

completely

timely

Question 37

True or false: personnel contributing to the health record must ensure that their name and professional designation are accurately identified both on paper and in electronic documentation.

Answer 37

True

Question 38

With the use of technology also comes the responsibility for nurses to use information wisely, to determine which data is collected, how this information is used, and to keep it s___ and confidential.

Answer 38

secure

Question 39

___ is used to deliver patient care. ___ extracted from the EHR will be used to make clinical decisions by various health care providers who will communicate with one another as they work together to provide quality care for a specific patient. This promotes continuity of care.

Answer 39

Data x2

Question 40

___ is used to support public health efforts. ___ in the health record is used to identify incidences of specific diseases, control disease, predict trends, and monitor the overall health of a population. Public health officials also use ___ to cure communicable and chronic diseases and reduce environmental hazards.

Answer 40

Data x3

Question 41

___ is evidence of patient care. Documentation of the course of a patient’s illness and treatment can be used for legal purposes. Who provided what care can be used to establish whether the applicable standard of care was met.

Answer 41

Data

Question 42

___ is used to evaluate health care. Organizations use ___ to support quality improvement activities.

Answer 42

Data

data

Question 43

In our health care system, data is stored in a patient’s ___ record.

Answer 43

health

Question 44

This can be either a paper-based record or an electronic form.

Answer 44

Health record

Question 45

A specific set of documents: a collection of data that contains a complete and accurate description of a patient’s history, condition, diagnostic and therapeutic treatments, and results of treatment.

Answer 45

Health record

Question 46

Contains detailed personal, financial, and social data about the patient.

Answer 46

Health record

Question 47

May also be called a medical record, a hospital chart, outpatient record, or clinical record.

Answer 47

Health record

Question 48

EHR

Answer 48

Electronic health record

Question 49

A patient record that uses an electronic system specifically designed to support users by providing accessibility to complete and accurate patient data, alerts, reminders, clinical decision support systems, links to medical knowledge, and other useful aids.

Answer 49

Electronic health record (EHR)

Question 50

A database that contains many different collections related to a specific patient and their care. This database can be accessed from multiple locations by multiple health care providers.

Answer 50

Electronic health record (EHR)

Question 51

True or false: paper-based health records are static, whereas an electronic health record provides instant access to the most current data.

Answer 51

True

Question 52

True or false: locating data using paper-based health records is difficult and requires an extensive manual search of the record. EHRs allow for easy searching, organizing, and sorting of data.

Answer 52

True

Question 53

Scanning a patient’s paper copy of their health record into the computer, with the belief that an electronic record is being created is a too common practice. In fact, this practice creates a digital record that is more ___ to use than the paper record because the information scanned in is not easily retrievable in a useful format and handwritten forms may be even more difficult to read.

Answer 53

difficult

Question 54

True or false: electronic information should be usable, retrievable, and accessible.

Answer 54

True

Question 55

When data is entered into a patient’s record, that data should be readily available for use any place that it is needed. Remember that every time a piece of data is re-entered, the likelihood of ___ increases.

Answer 55

errors

Question 56

The process of controlling, storing, retrieving, and using data to optimize its accuracy and utility while safeguarding its integrity.

Answer 56

Data management

Question 57

Nurses are actively involved in data ___ as they input and recall patient data.

Answer 57

management

Question 58

A file structure that supports the storage of data in an organized fashion and allows data retrieval as meaningful information.

Answer 58

Database

Question 59

Facilitate the collect of related records in a computer system and allow users flexible access to extract the necessary information that they require.

Answer 59

Databases

Question 60

The process of which great amounts of data are analyzed and investigated.

Answer 60

Data mining

Question 61

Uses a knowledge management software to uncover relationships within large data sets.

Answer 61

Data mining

Question 62

Has been utilized by marketing and politics to identify purchasing and voting trends and more recently by healthcare organizations to determine a variety of healthcare outcomes and patterns.

Answer 62

Data mining

Question 63

It can be used to sort through big data to track trends such as communicable diseases in communities and successful medical treatments for certain diseases.

Answer 63

Data mining

Question 64

Helps to discover or uncover previously unidentified relationships among the data in a database.

Answer 64

Data mining

Question 65

Documenting healthcare data using standardized terminology is vital to support data ___.

Answer 65

mining

Question 66

The process of analyzing health care data from different perspectives and summarizing it into useful information that can be used to improve patient safety and quality of care and cut costs. It has become an important tool to transform data into information.

Answer 66

Data mining

Question 67

A term that means that the user can view information by drilling down to a lower level of a database to focus on information that is pertinent to their needs at the moment.

Answer 67

‘Drill-down’

Question 68

___ use is using certified electronic health record (EHR) technology to improve quality, safety, efficiency, reduce health disparities, engage patients and family, improve care coordination, and population and public health.

Answer 68

Meaningful

Question 69

___ use is a Health IT standard related to the use of data transformed into information which generates knowledge and facilitates wisdom.

Answer 69

Meaningful

Question 70

Nurses collect ___ (e.g. client vital signs, symptoms) which they then interpret, organize, and turn into ___ about the status and care requirements of the client. This information, combined with other information about that client or amassed from other client experiences, is used to build new nursing ___ about client assessment, status, nursing interventions and outcomes.

Answer 70

data

information

knowledge

Question 71

A complete health record stored and accessed electronically under the custodianship of a healthcare provider that holds all relevant health information about a person over their lifetime.

Answer 71

Electronic health record (EHR)

Question 72

True or false: there are distinct differences between an electronic health record (EHR), a personal health record (PHR), and an electronic medical record.

Answer 72

True