Professional Role Flashcards

Question

HIPAA and Patient Care Situations 1. Putting patient charts on door box 2. Having sign-in sheets on front desk 3. Calling a patient in the waiting room to go inside the clinic exam room 4. Leaving messages on voice mail 5. Having a colleague who works in same clinic or hospital call, wanting information about a patient’s progress

Answer 1

1. **Putting patient charts on door box** 1. Place the chart so that the front of the chart is facing the door (so that patient name is hidden) 2. Limit access to certain areas; ensure area is supervised. 2. **Having sign-in sheets on front desk** 1. This is allowed if it does not list patient’s diagnosis. 2. Attendance list can show names, dates, and time 3. **Calling a patient in the waiting room to go inside the clinic exam room** 1. Use only first name. If more than one person with same first name, use the first letter of last name. 2. If you have two patients named Ann (e.g., Ann Lee and Ann Smith), use Ann L. and Ann S. 4. **Leaving messages on voice mail** 1. When calling, first provide your name and contact information. Be concise. Limit to 60 seconds. Maximum of three calls per week. 2. Information that can be given may include appointment reminders, notifications about prescriptions, and preoperative and postoperative instructions. 3. Avoid leaving messages about lab results, diagnosis, or other sensitive information on the patient's voicemail. 5. **Having a colleague who works in same clinic or hospital call, wanting information about a patient’s progress** 1. If staff member is not part of the healthcare team, no patient information can be released to that person. 2. HIPAA also does not allow such a person to access a friend’s or family member’s records without permission.

Answer 2

1. **Having a family member call, wanting information about a patient’s progress** 1. Put on hold and tell patient about the call. If patient gives permission, you can speak with the family member. 2. If patient does not consent, then advise the family member about the patient’s decision. Do not release patient information. 2. **Having inappropriate access of health information on the computer** 1. Viewing the records of your relatives, friends, or coworkers is an HIPAA violation 2. Do not allow someone to use your computer password. 3. **Using personal devices (smartphones, laptops, tablets) at work** 1. Ideally, it is best to avoid using personal devices at work. 2. *Requirements*: Secure Wi-Fi with passwords, regular encrypted backups, antivirus software, policies, etc 3. If you want to use a personal device, discuss it with your manager and/or consult information technology. Best practice is to use the facility’s or clinic’s devices. 4. **Discussing a patient’s drugs and other instructions with a health aide who is with the patient** 1. Discussing information is allowable. 2. If patient has the capacity to make healthcare decisions, discussing information is allowable 5. **Discussing patient’s treatment in front of a patient’s friend who is visiting** 1. Discussing treatment with the patient's friend is allowable if the patient gives consent or requests that the friend come inside the treatment room 2. Discussing patient information with others is allowable if patient agrees to it.

Answer 3

Psychotherapy records made by a mental health professional are treated differently under HIPAA. They should be separated from the patient’s other medical records. A separate consent form is needed to release psychotherapy records. The exceptions are mandatory reporting of abuse and **“duty to warn”** when the patient threatens serious and imminent harm to others. **“In situations where the patient is given an opportunity and does not object,** HIPAA allows the provider to share or discuss the patient’s mental health information with family members or other persons involved in the patient’s care or payment for care” (U.S. Department of Health and Human Services, 2017).

Answer 4

The health records of a minor (by law, an individual younger than 18 years of age) **can be released to parents** or legal guardians **without the minor’s consent.** If authorization is needed to release a minor’s medical record, the **parent or legal guardian must sign for it (except for emancipated minors). Emancipated minors can sign their own legal documents.**

Answer 5

Become familiar with how HIPAA is applied in real life. Study the HIPAA case scenarios It is a HIPAA violation to leave any laboratory results on a patient’s voicemail. Understand the role of an **ombudsman**, **guardian ad litem**, and others who act on behalf of a patient. * **Obudsman** = liaison/intermediary between patient and organization ie hospital (mediates complaints from both sides) * **Guardian Ad Litem** = guardian assigned by court (has legal authority) usually for incompetent adults/children/frail/vulnerable A **TPA (Third Party Administrator)** is the organization that does the processing of claims and administrative work for another company (health insurer, health plan, retirement plan).

Answer 6

This national health insurance legislation, officially known as the Patient Protection and Affordable Care Act (ACA) and unofficially nicknamed Obamacare, was signed by President Obama in March 2010 (and upheld by the U.S. Supreme Court in 2012), With the goal of expanding health insurance for the millions of Americans who were then uninsured. It expanded health coverage through various provisions (e.g., allowing adult children younger than age 26 to be insured under their parents’ healthcare insurance). This comprehensive reform of U.S. health insurance law prohibits an insurance company from rejecting people with preexisting health conditions. There is also a penalty for employers (and individuals) who choose not to participate in the national health plan. Although increased numbers of Americans gained insurance as a result of the law’s passage, many millions more still lack coverage.

Answer 7

**“COBRA” Consolidated Omnibus Budget Reconciliation Act of 1985** COBRA coverage is generally offered for 18 months (up to 36 months in some cases)

Answer 8

HMOs health maintenance organizations PPOs preferred provider organizations

Answer 9

Patients are assigned a primary care provider (PCP), who is the “gatekeeper.” The patient has a set “copay” per visit, and the participating physician/health provider is paid a set fee (per patient) monthly. The physician receives a monthly check from the HMO. ## Footnote * Specialist/consultant:* The PCP must first approve the referral. The patient is limited to seeing the physicians/specialists who are enrolled in the HMO’s network. * “Out-of-network physicians” or not referred by the PCP:* The visit may not be covered, or it will be reimbursed at a lower rate.

Answer 10

The patient can visit any provider in the network without a referral. Not assigned a PCP (as in HMOs). The patient can choose their own PCP. No referral is needed to see a specialist who is part of the PPO panel. PPOs are usually more expensive than HMOs.

Answer 11

Both Medicare and Medicaid programs are under the aegis of the **Centers for Medicare & Medicaid Services** (CMS). The CMS is one of the agencies under the **U.S. Department of Health and Human Services** (DHHS).

Answer 12

**“Automatic” at age 65** if the person paid the premiums (automatically deducted from paycheck by the employer). If the person never paid the premiums (e.g., full-time housewife), the person is not eligible for Medicare coverage. Also covers persons with **end-stage renal diseases** at any age. Certain religious groups (e.g., Amish, Mennonites) do not participate in Medicare.

Answer 13

***“medically necessary” services*** **Inpatient hospitalization (including inpatient psychiatric hospitalization)** **Hospice care** **Home healthcare** **SNF care** **Medicare Part A will not pay for custodial care (nursing homes, retirement homes).**

Answer 14

Medicare Part B is a **voluntary** program with **monthly premiums**. One must enroll during the **“general enrollment period.**”

Answer 15

1. **Outpatient visits (including walk-in clinics, urgent care clinics, ED visits)** 2. **Laboratory and other types of tests (EKG, x-rays, CT scans)** 3. **Durable medical equipment\*** 4. **“Second opinions” with another physician (surgery)** 5. **Kidney dialysis (outpatient), self-dialysis equipment/supplies, organ transplants, and many others** 6. **Ambulance service for emergency care or transportation to a hospital or SNF if transport in any other vehicle will endanger patient’s health**

Answer 16

* Most eyeglasses and eye exams (except following cataract surgery that implants an intraocular lens) * Hearing aids * Most dentures and dental care * Cosmetic plastic surgery (unless it is medically necessary) * Over-the-counter drugs and most prescription drugs

Answer 17

* Abdominal aortic aneurysm screening * Influenza shots once a year and Pneumovax and Prevnar 13 (each once in a lifetime) * Screening mammogram (once every 12 months for women age 40+) * Hepatitis B vaccine series for individuals at medium or high risk * Hepatitis C screening if high risk * Screening colonoscopy or flexible sigmoidoscopy (age 50 years or older) every 10 years if low risk * Routine Pap smears (once every 2 years or once every 12 months for women at high risk) * Prostate cancer screening (digital rectal exam [DRE] and prostate specific antigen [PSA] once a year after age 50)

Answer 18

* Bone density testing allowed once every 24 months if at risk for osteoporosis, taking prednisone, taking bisphosphonate therapy to monitor progress * HIV screening; sexually transmitted disease/infection screenings covered once every 12 months * Physical exams (once a year) * Smoking-cessation counseling and treatment * Alcohol misuse screening and counseling * Diabetes screening (twice yearly if at risk) * Cardiovascular disease screening

Answer 19

Medicare Advantage Plans cover **both inpatient care (Part A) and outpatient care (Part B),** and some plans cover **some prescription drugs.** They are administered by **private health insurance** companies approved by Medicare.

Answer 20

Medicare prescription drug benefit * Only individuals who are enrolled (or eligible) for Medicare Part A and/or Part B are eligible. * One type of Part D coverage is called the Medicare Advantage (MA) plan. * All prescription drug plans have a list of preferred drugs (the formulary). If a nonformulary drug is used, it may not be covered, and the patient has to pay for it “out of pocket.”

Answer 21

Authorized by Title XIX of the Social Security Act. A federal and state matching program. Provides health insurance coverage for **low-income individuals** and their families who meet the **federal poverty-level criteria.** Covers children, pregnant women, adults, seniors, and individuals with **disabilities** (e.g., blindness). Pays for **healthcare** and **prescription drugs**. Currently, Medicaid is the single largest payer for **mental health services** in the United States. It covers care offered by **substance use** disorder and **family planning services** (including contraception) as well as by maternal and infant health programs.

Answer 22

Cover **uninsured children** (infancy to adolescents) and **pregnant women.**

Answer 23

**Case Managers** Usually experienced RNs who act as coordinators for the outpatient management of patients with certain diagnoses, usually chronic, resource-intensive diseases (e.g., asthma [children], chronic obstructive pulmonary disease [COPD], chronic heart failure, diabetes). The process is called ***case management*****.** Case management is mainly done by telephone.

Answer 24

Patient-centered medical home (PCMH) is a healthcare delivery model that is also known as the *primary care medical home*. It is another way to deliver patient-centered primary care. In PCMH, the patient and family are considered important members of the healthcare team. Most of the patient’s healthcare needs are taken care of in the home setting. Other team members may include physicians, advanced practice nurses, physician assistants (PAs), nurses, pharmacists, nutritionists, social workers, educators, and care coordinators.

Answer 25

Delivery of healthcare is coordinated to ensure smooth transition between home and the hospital, home health agency, and community services. The patient and/or family has 24-7 access to a member of the team by phone, video chat, or email.

Answer 26

**Quality-Improvement Programs** The goal of these programs is to improve the quality of care, decrease complications, decrease hospitalizations, lower patient mortality, decrease system errors, and increase patient satisfaction. Patient outcomes are important indicators of a health system’s quality.

Answer 27

Risk management is an important aspect of quality-improvement/quality-assurance programs in the healthcare setting. It is the systematic organizational process used to identify risky practices to minimize adverse patient outcomes and corporate liability. For example, high-risk areas that are usually checked by risk managers are medication errors, hospital-acquired infections, patient identification problems, and falls. Risk management promotes safe and effective patient care practices.

Answer 28

**Accreditation** For example, the American Nurses Credentialing Center and the National League for Nursing Accrediting Commission are accreditation organizations.

Answer 29

**The Joint Commission**

Answer 30

**Sentinel Event** When an SE occurs, the healthcare organization is expected to conduct a **root cause analysis (RCA)**, make improvements to reduce risk, and monitor effectiveness of the improvements. **Accredited** organizations are strongly encouraged but are not required to report SEs to the **TJC**.

Answer 31

* Suicide that occurs while receiving care in a staffed around-the-clock facility or within 72 hours of discharge * Unanticipated death of an infant or discharge of infant to the wrong family * Rape or assault of a staff member, visitor, or vendor * Invasive procedure on the wrong patient, the wrong procedure is done on a patient, or the procedure is done to the wrong limb * Unintended retention of a foreign object * Fire, flame, or unanticipated smoke or heat during an episode of patient care

Answer 32

**Root Cause Analysis** A structured, facilitated team process used in healthcare to identify the contributing factors that result in an error. The TJC has mandated the use of this to analyze SEs. The gathered data are analyzed for the root causes (usually a combination of human, environmental, and system factors). The goal is to identify the system breakdowns that resulted in an inadvertent mistake and to propose at least one corrective action to reduce or eliminate each root cause. The focus is on the system and not on blaming individuals. **Sentinel Events**

Answer 33

**Outcomes Analysis**

Answer 34

The majority of hospice care in the United States takes place in patient’s homes (59% die in their own homes). The goal is palliative care, not curative care. Ensuring the patient’s quality of life and comfort are the ultimate goals of hospice care. Hospice care is available for both pediatric and adult patients. An interdisciplinary team provides hospice care. This team usually consists of the patient’s primary physician, hospice physician, RN, nursing assistants, therapists, social workers/grief counselor, and clergy. Hospice staff are on call 24 hours a day. They provide grief-and-loss counseling for patients and family members.

Answer 35

Hospice is covered under **Medicare Part A, Medicaid**, and most health insurance plans. Hospice patients are allowed to have physical therapy (PT), occupational therapy (OT), and speech therapy if prescribed

Answer 36

**Hospice physician and the patient’s physician certify** that the patient is **terminal** and has **6 months (or less) to live**. The hospice physician approves of admission. ## Footnote Patient is rapidly declining or exhibits worsening symptoms. Patient needs assistance with two or more activities of daily living (ADL). Patient accepts palliative care, not curative care. If they do not want to be in hospice (even if all criteria are met), then patient is not eligible.

Answer 37

***Examples of Terminal Conditions*** * Metastatic cancers (e.g., lung cancer, colon cancer) * End-stage lung disease (e.g., COPD) * End-stage heart disease (e.g., congestive heart failure [CHF] class III or IV) * End-stage liver disease * HIV/AIDS with comorbidities and refusal/discontinuation of antiretrovirals * End-stage renal disease with plan to discontinue dialysis * Amyotrophic lateral sclerosis, Parkinson’s disease, stroke, coma * End-stage dementia (e.g., Alzheimer’s disease)

Answer 38

**Respite Care**

Answer 39

**Healthy male** = empty square **Disease/affected male** = filled square **Healthy female** = empty circle **Disease/affected female** = filled circle **Dead person** = diagonal dash across symbol

Answer 40

A patient may meet the criteria for hospice admission, but if the patient **refuses** hospice care, then the patient is **not eligible**. If the patient meets the criteria for **hospice** care, **Medicare Part A** will reimburse hospice. Medicare Part B **will pay** for an **ambulance** for emergency care. If transport in any other vehicle will endanger the patient’s health, transport by ambulance is allowed. Medicare Part B **does not reimburse** for **dentures**, **eyeglasses**, or **hearing aids**. **COBRA** is a law that allows a person to continue group health insurance coverage from a job even if they have quit (the individual has to pay the insurance premiums). **No separate consent** is required for entities that pay or process the patient’s health bills, such as health insurance companies, HMOs, medical billers, or collection agencies (or third-party contractors hired by the company to pay or to process claims).

Answer 41

The **“medical home”** is a method of primary healthcare delivery. Healthcare providers and therapists (physical, occupational, speech) deliver care in the patient’s home, with the family. These patients have chronic long-term illness. To communicate, technology is used, such as phone, video chat, or email. Use common sense in answering questions on quality improvement and risk management. Keep in mind the goals of these processes: **to improve the quality of care, decrease complications, decrease hospitalizations, lower patient mortality, decrease system errors, and increase patient satisfaction. Look for the answer that fits these goals**. Learn the human genetic symbol for a diseased (or affected) male and female = **filled in square (diseased male), filled in circle (diseased female)**

Answer 42

Loretta C. Ford, PhD, RN, FAAN, and Henry K. Silver, MD, started the first nurse practitioner (NP) program at the University of Colorado in 1965. Initially, it was a certificate program and later became a master’s program in the 1970s. The first NPs were pediatric NPs who practiced in poor rural areas where there were no physicians (because of a severe shortage of primary care physicians).

Answer 43

An NP must meet the minimal educational requirements that are mandated by the **nurse practice act of the state** (where they plan to practice).

Answer 44

The nurse practice act is enacted into law by the state legislature. Therefore, the NP’s legal right to practice is derived from the state legislature. Each state has its own nurse practice act that contains regulations that dictate the educational requirements, responsibilities, and scope of practice for NPs and other nurses (e.g., RNs, licensed practical nurses, midwives) who practice in the state. NP practice is not regulated by the federal government, the American Medical Association (AMA), or the U.S. Department of Health and Human Services (DHHS).

Answer 45

**The state board of nursing (SBON) is responsible for enforcing the state’s nurse practice act.** The SBON is a formal governmental agency that has the statutory authority to regulate nursing practice. The SBON has the legal authority to license, monitor, and discipline nurses. The SBON is also authorized to revoke a nurse’s license (after formal hearings).

Answer 46

*Title Protection* Professional designations, such as RN, NP, or APRN, are protected by law. It is illegal for any person to use these titles without a valid license. Title protection is under mandate by a state’s nurse practice act. Title protection protects the public from unlicensed “nurses.”

Answer 47

The **legal requirement** to practice as an NP It is obtained through a governmental entity, the **SBON**. The NP must meet the minimal educational and clinical requirements in order to become licensed.

Answer 48

A “**voluntary**” process and is done through a nongovernmental entity such as a professional nursing association or specialty organization. . The majority of states in the United States now mandate board certification (or certification) as a condition to obtain licensure.

Answer 49

**Standards are authoritative statements of the duties that all RNs, regardless of role, population, or specialty, are expected to perform.** According to the American Nurses Association (ANA), these include both the Standards of Practice and the Standards of Professional Performance. They are developed by professional societies (e.g., ANA) as well as specialty organizations; for example, the American Association of Nurse Practitioners (AANP) publishes *Standards of Practice for Nurse Practitioners (AANP, 2019).*

Answer 50

*Collaborative Practice Agreements* ## Footnote A copy of the collaborative practice agreement must be kept at the NP’s practice setting and mailed to the SBON. Most states require an annual review of the agreement that contains signatures of the individuals involved and dates. The state practice environment differs for each specific state. Some states allow full practice under the exclusive authority of the SBON, some states allow reduced practice, and some have restricted practice. In these states, the NP must be under the supervision or delegation of an outside health discipline such as the Board of Medicine.

Answer 51

NPs can sign collaborative practice agreements with physicians (MDs), osteopaths (DOs), and dentists/dental surgeons (DMDs/DDSs). Chiropractors (DCs) and naturopaths (NDs) are not considered physicians under nurse practice acts. In most states, physicians are the only practitioners who can legally sign a death certificate.

Answer 52

The majority of states require NPs to have a written practice protocol with a supervising physician in order to prescribe drugs. The protocol usually contains the list of drugs (by name, class, or condition) that an NP is allowed to prescribe. In the United States, all 50 states grant prescriptive authority to NPs, including the right to prescribe controlled substances (varies by state).

Answer 53

* NP’s name, designation, and license number * Clinic’s name, address, and phone number; if the practice has several clinics, the other clinics where the NP practices should also be listed on the pad. * To reduce fraud, it is best if the DEA number is not listed (only for controlled substance prescriptions).

Answer 54

Tamper-resistant prescription pads are required by Medicare and Medicaid, as well as when prescribing Food and Drug Administration (FDA)–controlled substances. A controlled substance prescription can be typed, but it must be signed by the prescribing practitioner the day it is issued.

Answer 55

Substances in this schedule have a high potential for abuse with severe psychological or physical dependence. These cannot be called in. They must be written on tamper-resistant pads and signed by the prescriber (not stamped). There is some variation among the different state laws regarding prescriptions of Schedule II drugs. *Examples:* Codeine, morphine, hydrocodone, oxycodone, opium, fentanyl, methadone, amphetamines.

Answer 56

A method of sending prescriptions **electronically directly to the pharmacy** Preferred method of prescribing by Medicare and Medicaid

Answer 57

“Silent Generation” Baby Boomers Generation X (Gen Xers) Generation Y (millenials) There are now three generations that work side by side. The “Silent Generation” group has retired. Each generation behaves differently

Answer 58

**Baby Boomers** Born from 1946 to 1964. Hard workers. Like to achieve. More susceptible to burnout and stress-related illness. **Generation Y (Millennials)** Born from 1981 to 2000. Multitaskers who seek learning and career development but also value free time to socialize. **“Silent Generation”** Born from 1925 to 1945. Disciplined and loyal. Traditional work ethic. More action oriented. The youngest nurses from this generation are now in their 70s, and most have retired. **Generation X (Gen Xers)** Born from 1965 to 1980. Question authority, expect immediate results. They are loyal to peers over the company.

Answer 59

**Situational Leadership** **Transformational Leadership** **Laissez-Faire Leadership** **Authoritarian Leadership (Autocratic)** **Democratic Leadership** **Servant Leadership**

Answer 60

**Laissez-Faire Leadership**

Answer 61

**Democratic Leadership**

Answer 62

**Transformational Leadership**

Answer 63

**Authoritarian Leadership (Autocratic)**

Answer 64

**Situational Leadership**

Answer 65

**Servant Leadership**

Answer 66

**Claims-Based Policy** **Occurrence-Based Policy**

Answer 67

This type of malpractice insurance covers claims only if the incident occurred when the NP **paid the premium** *and* only if the NP is still **enrolled with the same insurance company at the time the claim is filed** in court.

Answer 68

The claim will not be covered (in the future) if they do not have the same insurance company as when the lawsuit was filed. - **NEEDS INSURANCE AT TIME OF CLAIM** **“Tail Coverage”** Buying “tail coverage” can help address this issue. Tail coverage insurance will cover the NP for malpractice claims that may be filed against them in the future. When an NP with claims-based malpractice insurance retires or changes jobs, it is advisable to buy tail coverage insurance.

Answer 69

This type of malpractice policy is not affected by job changes or retirement. If a claim is filed against the NP in the future, it is **covered if they had an occurrence-based policy at the time the incident occurred.** ## Footnote ***Example:*** An NP who has been retired for 2 years has a claim filed against her for an incident that occurred while she was employed and insured. Since she carried an occurrence-based policy, the claim will be covered.

Answer 70

* Plaintiff:* The patient or whoever is acting on behalf of the patient (e.g., the patient’s representative) who files the lawsuit claiming injury and/or damage by another party * Defendant:* The party who responds to the lawsuit filed by another party who claims an injury and/or damage (e.g., NP, hospital

Answer 71

* A duty is owed (a legal duty exists). * The duty was breached (e.g., not following standard of care). * The breach caused an injury (proximate cause). * Damage occurred.

Answer 72

A lawsuit is filed in the appropriate court. The “discovery” phase (e.g., requesting of medical records, depositions, expert opinions) occurs. Plaintiff has the “burden of proof.” Court trial phase (or settle out of court or arbitration) occurs. The judgment is given. Either the case is dismissed, or damages are awarded (e.g., physical harm, emotional/mental harm).

Answer 73

Ideally, the NP who will testify as an expert witness should be someone who practices in the same specialty and geographic area as the NP defendant. For example, an NP who practices in Los Angeles, California, may not be the best choice as an expert witness for an NP who is being sued and who is practicing in Miami, Florida.

Answer 74

**Budget Reconciliation Act of 1989 (HR 3299)**

Answer 75

**Balance Budget Act of 1997** The Health Insurance Portability and Accountability Act (HIPAA) of 1996 required health providers to have a **National Provider Identifier (NPI)** number to bill Medicare and Medicaid. NPs can be reimbursed directly by **Medicare Part B**, Medicaid, Tricare, and some health insurance plans. Medicare will reimburse NPs at **85**% of the Medicare Physician Fee Schedule.

Answer 76

The NPI is a unique 10-digit identification number assigned to healthcare providers (or to any entity that bills Medicare/Medicaid). It is issued by the National Plan and Provider Enumeration System (NPPES). All providers who provide services and bill Medicare must have an NPI number. Individual healthcare providers may obtain only one NPI for themselves. To become a Medicare-approved provider, one must first obtain an NPI number online. An individual provider’s NPI identifier lasts for their lifetime. The identifier does not change regardless of state or group affiliations. Medicare requires the NPI number for financial transactions. Electronic claims submission is required by Medicare and Medicaid. Medicare uses electronic fund transfer (EFT) to reimburse providers.

Answer 77

“Incident-to” billing is a way to bill Medicare for outpatient services rendered by a **nonphysician health provider (NP, PA**) and receive the **100% physician fee**. The location of the services can be at the physician’s office, a separate or satellite office, or an institution or in the patient’s home.

Answer 78

During the first visit, the physician must evaluate the patient (and write a care plan). Follow-up visits by the NP can be billed as “incident to” so long as the same health problems are being addressed. The physician’s NPI number is used to bill for the service. The “incident-to” billing is reimbursed at 100% of the physician rate. But if the same patient is seen for a new problem by the NP (or PA), then the visit is billed under the NP’s or PA’s NPI number (85% of physician fee).

Answer 79

Every time an NP bills Medicare, Medicaid, and/or a health insurance plan, they must submit an electronic claim. The claim form, or the “superbill,” must contain both the *International Classification of Diseases*, 10th edition (***ICD-10**)*; World Health Organization [**_WHO], 2016_**) code(s) or the diagnosis and the Current Procedural Terminology (**CPT**) code(s). If a bill is missing the *ICD-10* code or CPT code, the bill will be rejected (not paid) and it has to be resubmitted with the required information. The services rendered must show medical necessity and the appropriateness of diagnostic and/or therapeutic services that were completed.

Answer 80

The *ICD-10* code is used to indicate the patient’s **diagnosis** as determined by the *International Classification of Diseases*, 10th edition (**_WHO, 2016_**). Each disease is assigned a specific *ICD-10* code.

Answer 81

*ICD-10* uses Z-codes to indicate the **reason for each patient encounter.** If a procedure is performed, a corresponding CPT code must accompany each Z-code (e.g., to justify the procedure, vaccinations, screening, counseling, others).

Answer 82

The CPT is a five-digit code or alphanumeric code (letter with the digits) that is used to identify **medical procedures** (suturing, incision and drainage [I&D]) and other medical services. It is owned and maintained by the AMA.

Answer 83

Evaluation and Management Service (E&M) codes are used to bill for patient visits and are part of the CPT. If a bill is missing an E&M code, the healthcare provider will not be reimbursed for the time they spent with the patient. E&M codes are based on the history, examination, and medical decision-making (complexity) that take place. The provider must document that these three components have been met (or exceeded). The complexity and time spent with the patient are assigned codes by the CPT system.

Answer 84

*Telehealth*

Answer 85

*Telemedicine*

Answer 86

(HITECH Act) Health Information Technology for Economic and Clinical Health Act The act included incentives for early adoption of those technologies until 2015. After 2015, it began to issue financial penalties (e.g., reductions of Medicare and Medicaid reimbursement) for providers and entities who had not adopted EHR technologies. In addition, it strengthened enforcement of HIPAA security and privacy laws and penalties for breaches.

Answer 87

NPs receive their “right to practice” from the state legislature. Identify a problem-focused visit (see example in “What Are E&M Service Codes?”) = just needs chief complaint and HPI, does not need ROS, past, family, or social history There are various types of nursing leadership. Claims-based malpractice insurance will cover claims only if the NP is still enrolled with the same insurance company at the time the claim is filed in court. Occurrence-type malpractice insurance will cover a lawsuit in the future even if the NP no longer carries the policy, as long as the NP had an active policy during the alleged incident.

Answer 88

The NPI contains 10 numbers/digits. The *ICD-10* is used for diagnosis codes. The CPT code is used to bill for outpatient office procedures and services. Both the *ICD-10* and CPT codes are required for each bill. “Incident-to” billing is used for Medicare patients and refers to billing of a follow-up visit performed by a nonphysician provider billed under the physician’s NPI number (the nonphysician provider is paid 100% vs. the rate of an NP or PA, who receives only 85%).

Answer 89

Culturally competent care improves patient satisfaction and patient safety (e.g., by reducing medication-related errors). To provide culturally competent care, the APRN must develop knowledge, skills, and positive attitudes about diverse cultures and work individually and within the healthcare system to promote care that is respectful of all cultures. If a cultural practice has an adverse effect on a patient’s health, then the nurse practitioner (NP) needs to explain to the patient in a sensitive manner the reason for not following the practice. ***Example:*** A female patient tells the NP that her shaman (*curandero*, in Spanish) “told me not to take my medicine but to drink herbal tea instead” or “told me not to drink water for 2 days.” The NP respectfully explains to the patient why the practice is harmful to her health.

Answer 90

Madeleine Leininger is recognized as the founder of transcultural nursing and credited with the construct of “culturally congruent care.” This theory defines culture as “the specific pattern of behavior that distinguishes any society from others and gives meaning to human expressions of care” (Leininger, 2014). Leininger’s Sunrise Model is likely the most frequently used to frame culturally competent nursing care and research. The Sunrise Model recognizes that care is influenced by many cultural features (e.g., technology, religiosity or spirituality, kinship and social structures, cultural values and beliefs and practices, legal and political systems, economics, and education), all of which shape one’s worldview.

Answer 91

Cultural and Spiritual Awareness This is defined as **“being knowledgeable about one’s own thoughts, feelings, and sensations, as well as the ability to reflect on how these can affect one’s interactions with other”**

Answer 92

African Americans often use **religious coping**—typically Christian (e.g., prayer, gospel music, Bible reading, engagement with faith community). Christian pastors and preachers are held in high esteem. Church congregations and religion may be important sources of emotional and tangible support. Some patients may feel that their illness is caused by lack of faith or by sin. Many families have a female head of household (matriarchal).

Answer 93

Latino families have a strong **matriarchal element**, and the (1) gender parent is an important source of strength and solace in times of illness. People from various Latino cultures may consult folk healers. * ***Susto*** cultural illness (*susto* means “fright”). * ***Mal de ojo*** the **“evil eye,**” is a folk illness (usually of a baby/child). * It is caused by an adult who **stare with envy** at the child. (This is similar to the belief in an “evil eye” among some Muslim and Mediterranean cultures.) * The hex can be broken if the person staring at the child **touch the child.** * Another way to break the hex is to pass an **egg** over the child (with prayers) and then place the egg under the bed overnight. In general, Hispanic families enjoy public affection. Extended family are treated like immediate family. Multigenerational households are common.

Answer 94

There are 574 federally recognized Indian Nations (also known as tribes, villages, bands, pueblos, rancherias, or communities) and Alaskan Native tribes in the United States. These many and varied groups have differing cultural practices and beliefs, but most traditionally view **illness as “punishment”** by the spirits for wrongful actions. Healing is done by **shamans** using prayers, dance, fasting, smudging, and sometimes ingesting hallucinogenic plants (peyote). **Smudging** is the ritualistic burning of an herb (with prayer) to help cleanse a person or place. Some groups use medicine pouches, tied to the patient by a string, to help cure the illness.

Answer 95

American Indian and Alaska Native people have **lower health status when compared with other Americans.** Their life expectancy is 5.5 years less than the U.S. all-races population (**_Indian Health Service, 2019_**). American Indian and Alaska Native people die at higher rates than other Americans from chronic liver disease/cirrhosis, diabetes, accidents, assault/homicide, self-harm/suicide, and chronic lower respiratory disease. About 16% of persons (all ages) are considered in fair or poor health. The leading cause of death is heart disease (Centers for Disease Control and Prevention, 2017). Among men and women aged 18 years or older, about 20% are smokers.

Answer 96

American Indian women have the **highest rates of rape and assault** in the United States. They are 2.5 times more likely to experience sexual assault and rape compared with other ethnic groups in the United States (Gilpin, 2016). The **Indian Health Service**, a federal agency, is charged with delivery of healthcare to this population.

Answer 97

East Asians (Chinese, Vietnamese, Cambodian, Korean, Japanese) highly value college education and have high regard (respect) for doctors. Listening quietly without questioning is considered a sign of respect. Some think that asking questions (or disagreeing) with the treatment plan shows lack of respect. Kinship ties are very important. Several generations may live in the same household. Elderly are held in high esteem, and their opinion is highly respected. Some Asian cultures have a form of “ancestor veneration” practices. In China, the male child is expected to take care of parents when they age

Answer 98

* May stop taking prescription medicine when symptoms resolve or may think that only one visit is needed to “cure” an illness * Often save large quantities of leftover prescription drugs * May fear blood tests and surgery because of a belief that blood loss worsens illness * May believe that Western medicine will put the body out of balance

Answer 99

* Majority come from Asia (e.g., Cambodia, Thailand, Bhutan, Japan, Laos, Vietnam, Taiwan, Tibet) * Main deity is Buddha; they believe that physical **suffering is an inevitable part of life** and believe in **karma** (“good deeds” create happiness, and “bad deeds” create pain in the future) and the cycle of rebirth (reincarnation); some dying Buddhists may experience anxiety about being reborn into a lower form or less desirable life * May be **vegetarian** * May practice regular **meditation**; Buddhists value clarity of mind and may refuse narcotics or medications that alter consciousness

Answer 100

* Practitioners believe life energy (**chi or qi**) imbalance or blockage is the cause of disease. * **Yin** is the female, and **yang** is the male. * Believe **acupuncture** and **cupping** correct energy imbalance. * **Cupping** will create large round reddened marks or bruises on back (after 24 hours). **Coining** is when a coin is rubbed vigorously on skin to create welts. Both of these practices may produce lesions that may be misinterpreted as signs of abuse. The NP should question how a child received such lesions before reporting the lesions as abuse.

Answer 101

Baptized Sikhs (Khalsa) and some others will obey a code of conduct that stipulates one wears **five symbols of Sikh identity: uncut hair, a sword, shorts, hair comb, and iron wrist ring.** These symbols should not be removed unless negotiated with the patient. Sikhs will **not consume meat, alcohol, or stimulants.** Adult male Sikhs may wear a **large turban**-like head covering (usually white color). Most come from southern or Southeast Asia, India, Canada, United Kingdom, and the United States.

Answer 102

A central belief of Hinduism is the doctrine of **karma**, the law of cause and effect, which can affect decision-making regarding healthcare. All illness may be seen as the result of karma. Hinduism encourages the **acceptance of pain and suffering** as part of the consequences of karma. Hindu patients **may not be forthcoming about pain and may prefer to accept it as a means of progressing spiritually.** Hindus believe that all **illnesses have** a **biological, psychological, and spiritual element.** Treatments that do not address all three causes may not be considered effective by a Hindu patient. Many Hindus attach a **stigma to mental illness and cognitive dysfunction.** Hindus believe that the time of **death is determined by one’s destiny and accept death and illness as part of life.**

Answer 103

Most Hindus do not eat beef or pork, and many follow a vegetarian diet. Fasting is an integral part of Hinduism and is seen as a means of purifying the body and the soul. May wear a talisman that should not be cut or removed. Countries with highest percentage of Hindus are Nepal, India, and Mauritius.

Answer 104

In traditional Muslim families, **Sharia law** (Islamic law) is followed. **Modesty** is paramount; garments of adolescent females and women should cover arms, legs, and head. A **hijab** is a head scarf (hides hair, ears, neck), and the **burqa** or **abaya** is the full veil/robe that covers the body. The **left hand** is reserved for bodily functions (considered unclean). Shake the patient’s hand by using your right hand. **Clinicians of same gender preferred**. Some male patients may be uncomfortable receiving healthcare from a female health provider. An unmarried woman needs her father’s permission to see a clinician, and a married woman needs her husband’s permission. In addition, **women are not allowed to be alone** or to visit with men who are not family members. If a woman is seen by a male health provider, her husband or another male family member must be present in the room. The female patient may **refuse to undress (examine with the gown on).**

Answer 105

The Qur’an (Koran) forbids drinking alcohol, eating pork, or eating meat not slaughtered in the “halal” manner. The holy month of Ramadan is observed by 30 days of fasting. * It is forbidden to eat or drink fluids/water during the daytime, but one can eat or drink from sunset to before sunrise. * If possible, schedule oral medications after sunset. * Those who are sick may be exempted (pregnant women, physically or mentally ill people). * Children are not expected to fast until puberty.

Answer 106

Orthodox Jews, such as Hasidic Jews, prefer clinicians of the same gender. Male Hasidic Jews may refuse to shake a female clinician’s hand. Female Hasidic Jews wear a wig to cover their hair. Shabbat (Sabbath) is observed from sundown Friday to sundown Saturday as a holy day that forbids any form of work. * Some believe that electricity is a form of work and may stop using light switches or any electronic equipment during Shabbat (may have to turn on the light switch for the patient). * Some observant Jews do not drive or use cell phones or other personal electronics at this time. * If possible, avoid accessing unnecessary health services on the Sabbath and avoid scheduling follow-up visits or tests on the Sabbath.

Answer 107

Jews may keep kosher dietary laws (kashruth; e.g., not mixing meat and dairy products within specified time frame, eating only meaty foods certified as kosher). Families may have two separate kitchens at home: kosher and nonkosher. Each kitchen has its own utensils, pots, and plates (not allowed to mix because the kosher items will become contaminated).

Answer 108

Jehovah’s Witnesses **refuse to donate blood, store blood, or accept own blood (autologous transfusion) but accept nonblood plasma expanders and blood components without red blood cells** (RBCs; albumin, cryoprecipitate, clotting factors, immunoglobulins). If a blood transfusion is needed to save the life of a child, **parents may refuse (may require a court order).** Believers **do not celebrate** civil holidays, birthdays, Christmas, Easter, and others. Healthcare providers should encourage believers to carry an advance directive or medical release form that states their convictions; such a card is available from the church. In urban locations, a hospital liaison from the church may be available to support believers with decision-making.

Answer 109

Believers are often vegetarian and abstain from tobacco, alcohol, and caffeinated beverages. Adventists believe the human body is a temple of God that deserves care (healthy lifestyle). They observe Sabbath (sundown Friday to sundown Saturday) as a holy day for rest from work/school and spiritual nurturing. If possible, avoid accessing unnecessary health services on the Sabbath.

Answer 110

Believers do not participate in Medicare or Social Security or go to war. The individual’s community pays for healthcare (**no health insurance).** Use of folk practitioners and folk/alternative medicine is common. If surgery or an expensive test is needed, permission from church elders is required. Believers may speak German dialect. They **avoid modern technology,** such as telephones and electricity, and use horses and buggies for transportation. Large families, traditional roles for women, and agricultural work are characteristic. Amish prefer giving birth (using midwives) and dying at home. These closed communities have higher rates of some **genetic diseases** such as maple syrup urine disease, Crigler–Najjar syndrome, a type of dwarfism (Ellis–van Creed syndrome), and cystic fibrosis, as well as certain metabolic disorders.

Answer 111

Mormon churches provide a strong social support network for the ill. The local ward bishop, elders, missionaries, home or visiting teachers, and/or lay people provide spiritual and temporal support. Patients may wear “temple garments” under hospital gown or clothing as a symbol of covenant they made in the temple. Treat such undergarments with respect.

Answer 112

Avoid assumptions regarding sexual orientation or gender identity. Facilitate disclosure while remaining respectful of an individual’s “coming out” process. Recognize and support the patient’s family of choice and use gender-neutral language on forms and during history taking (e.g., “Have you had sex with a male, female, both, or neither?”). Respectfully ask how the patient wants to be addressed and what pronouns to use (e.g., *he* vs. *she*). Many LGBT people have been mistreated by the medical community and are reluctant to obtain healthcare unless absolutely necessary. Organizations like the Yes Institute in Miami maintain lists of culturally competent LGBT healthcare providers ([**https://yesinstitute.org**](https://yesinstitute.org/)). The National LGBTQIA+ Health Education Center, a program of the Fenway Institute, provides educational programs, resources, and consultation to healthcare organizations with the goal of optimizing quality, cost-effective healthcare for lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexual and gender minority people

Answer 113

**PTSD, TBI** are prevalent among U.S. veterans. Military personnel are accustomed to self-protect when exposed to certain sounds or experiences (e.g., hide under bed when helicopter is overhead). They are socialized to be stoic about pain or suffering and nonquestioning of authority figures. It is important to include the patient’s family in their care, as they are aware of the military culture.

Answer 114

Health Literacy It affects the person’s ability to learn about how to access healthcare, complete forms, respond to questions, implement recommended treatments, and so forth. It depends on communication and language, existing knowledge about health, culture, and numerical ability and skills, as well as the demands of the situation and system within which the individual presents.

Answer 115

Even one misunderstood or misspoken word can affect a patient’s decision-making or implementation of a treatment. Strategies for communication between patients and healthcare providers who speak different languages include language access services (virtual, telephonic, or in-person interpreters) and handheld documents at point of service that present clinicians with patient information. Untrained staff and family members should not be used for interpretative services.

Answer 116

Cultures are often categorized as *individualistic* or *collectivistic*. Individualist societies value the individual above the family, organization, or group. In contrast, collectivist societies consider the rights, needs, and wishes of the family or group over those of individuals.

Answer 117

* What do you think has caused your illness? (Etiology) * Why do you think it started when it did? (Onset of symptoms) * What do you think your illness does to you? How does it work? (Pathophysiology) * How severe is your illness? Will it last a short or long time? (Course of illness) * What kind of treatment do you think you need? What results do you hope for? (Treatment) * What are the biggest problems your illness has caused you? * What do you fear most about your illness? Noncompliance and other problems are usually explained by a discrepancy between the patient’s and professional’s interpretation of the illness. When the explanatory models for the illness do not align, the clinician must seek to understand and negotiate them as a “therapeutic ally” with the patient.

Answer 118

Muslim women who refuse to wear a gown can be examined through their clothing (modified or partial physical exam). Jehovah’s Witnesses do not accept blood transfusions (including autologous), but some may accept blood components without RBCs (e.g., cryoprecipitate, immunoglobins). Prolonged direct eye contact with males or strangers is considered rude by some cultures (e.g., Asians, female Muslim). Ramadan is a Muslim holiday that lasts for 30 days. Both fluids and food are forbidden from sunrise to sunset. Orthodox Jewish patients may refuse to touch anything powered by electricity (e.g., light switch, call light, electronic pumps, cell phones) from sunset Friday to sunset Saturday (Sabbath). Do not schedule visits during the Sabbath. If you call during this time, observant patients will not answer the phone.

Answer 119

Each person interprets and implements their cultural and religious beliefs and practices uniquely; therefore, the clinician should make no assumptions and assess as needed. In other words, talk to the patient and actively listen and verify what is being said. Religious practices often influence behavior around birthing, marriage, child rearing, illness, death, burial, and mourning. Patient beliefs and practices should be honored, provided they do not cause harm.

Answer 120

Primary Sources = research from which the data originated Secondary Sources = sources created where the original data (primary data) are interpreted or analyzed by another person (not the original researcher) “second hand accounts” **Primary Sources Preferred**

Answer 121

**Institutional Review Boards (IRB)**

Answer 122

The members of the IRB committee are formally designated to review and monitor research that involves human subjects at their institution. The IRB members are individuals who are **affiliated** with the institution. Therefore physicians, clinicians, or retail pharmacists who are not affiliated with the institution are generally not included in an IRB committee (unless they are hired as consultants). In addition, **experienced staff members**, not recent graduates, are preferred. The size of the IRB and the number of members depend on the type of institution.

Answer 123

* Infants and children younger than 18 years of age * Pregnant women, fetuses * Prisoners * Refugees, ethnic minorities * Persons with mental or physical disabilities, visual or hearing impairment * Persons who are economically disadvantaged

Answer 124

**Belmont Report**

Answer 125

**Tuskegee Syphilis Experiment**

Answer 126

Research subjects must be informed that they have the **right to withdraw** from the research study at any time without adverse consequences or penalty. There are additional requirements for minors and vulnerable subjects. * Describe the study. Inform the subject of what they are expected to do (e.g., questionnaires, labs). * Describe the risk or the discomforts of participating in the study in the present and the future (if applicable). * Describe the benefits of participating in the study in the present and the future (if applicable). * Discuss the alternatives to the study. Allow enough time for the subject to ask questions. * Discuss whether there is any compensation or reward for participation. * Discuss how confidentiality and data will be secured to protect the subject’s identity. * Give the number and/or email address of the contact for the study so that the subject can contact that person if they have any concerns or problems with the study.

Answer 127

\<18 yo ***Emancipated Minor Criteria*** * Legal court document declaring that the minor is an “emancipated minor” * Active duty in the U.S. military * Legally binding marriage (or divorced from a legally binding marriage)

Answer 128

**Consent** may only be given by individuals who have reached the legal age of **consent** (**in the** U.S. this **is** typically 18 years old). **Assent is** the agreement of someone not able to give legal **consent** to participate **in the** activity **(the expression of approval)** Consent may be given only by individuals who are aged 18 years or older. A minor (who is not emancipated) as young as the age of 7 years up to age 17 years can give assent to participate in a research study but cannot give consent legally. The child should be assured that they can withdraw from the study after discussing it with their parents. The parent or legal guardian must first consent to the minor’s participation in the study. In addition, the researcher needs parental permission to speak with the minor in order to obtain assent (the child signs a separate assent form).

Answer 129

***α**:* Also known as the “significance level” or “*p*-value.” It is usually set as either *p\< 0.05* or *p* \< 0.01 * A significance level of *p \<* 0.05 means that there is a 5% probability that a study's results are due to chance * A significance level of *p \<* 0.01 means that there is a 1% probability that a study's results are due to chance. Therefore a ***α*** of *p \<* 0.01 is “better” than an *α* of *p \<* 0.05 *Significance level:* Also known as the “α” or a *“p*-value.” The *p*-value is usually set at either *p\<0.05* or *p\<0.01*

Answer 130

* Control group**:* Subjects in an experiment who do not receive treatment. * N*: This letter indicates the total size of the sample. * n*: This letter indicates the number of subjects in the group.

Answer 131

Variables * Independent variable:* Variable that is being manipulated and is used to influence the dependent variable. In experimental studies, the researcher has control over the independent variable. * Dependent variable**:* This is the result of the manipulation of the independent variable. * Example:* Manipulation by researcher (independent variable) allows a response to manipulation that can be observed and measured (dependent variable).

Answer 132

*Hypothesis*

Answer 133

This is the opposite of the hypothesis being studied. REJECT THE NULL: If the research data meets the set *p*-value (*p* \< .01), the results are considered significant (not due to random chance), and the null hypothesis can be rejected. *Example:* If the hypothesis is “corn plants grow faster when exposed to sunlight,” the null hypotheses is “corn plants will not grow faster when exposed to sunlight.” If the research data meets the set *p*-value (*p* \< .01), the results are considered significant (not due to random chance), and the null hypothesis can be rejected. If the null hypothesis cannot be rejected, it means that there is no relationship between the variables, and the results are due to chance.

Answer 134

bell-shaped curve

Answer 135

Mean: Also known as the average. Calculated by adding all of the scores together and dividing it by the total number. * Example: 5, 5, 5, 10, 10 (35 ÷ 5 = 7, average is “7”) Median: The number that is in the middle when values are arranged from lowest to highest (chronological order) * Example: 1, 3, 4, 5, 7, 10, 14 (median value is “5”) Mode: The most common value or frequently occurring value in a set of scores * Example: 3, 5, 7, 7, 7, 8, 9, 10, 10 (mode is “7”) Range: The difference between the largest and smallest values in a distribution * Example: 2, 3, 5, 7, 10, 15 (15 − 2 = 13, range is “13”)

Answer 136

**Prospective Study**

Answer 137

**Retrospective Study**

Answer 138

**Longitudinal Study**

Answer 139

**Cohort**

Answer 140

**Cross-Sectional Study**

Answer 141

**Case Study**

Answer 142

**Descriptive**

Answer 143

**Correlational** 1. *Positive correlation:* Two variables change together in the same direction. For example, when variable A increases, then variable B also increases. 2. *Negative correlation:* An increase in one variable results in a decrease in the other. For example, when variable A increases, this causes variable B to decrease. 3. *No correlation:* The variables are not related. For example, a change in variable A does not affect variable B

Answer 144

**Experimental Study**

Answer 145

**Quasi-Experimental**

Answer 146

**Deductive Reasoning**

Answer 147

**Inductive Reasoning**

Answer 148

* Phase I—Conception:* Formulate research problem or question; review literature; develop hypothesis(es) * Phase II—Design and Planning:* Select research design; identify population/sample; determine protocols, methods, resources required, and ethical considerations; prepare proposal; submit to IRB for approval * Phase III—Implementation**:* Recruit participants (obtain consent); implement research design; collect data * Phase IV—Analysis**:* Organize, analyze, and interpret data * Phase V—Dissemination:* Prepare final report; publish and disseminate findings (e.g., journal articles, poster presentations, lectures)

Answer 149

Primary data are the preferred source in research (original study that produced the data). Experimental studies use randomization with subject selection. Correlational studies search for relationships between a minimum of two variables. Deductive logic is used with quantitative studies, and inductive logic is used in qualitative studies. Understand the difference between a dependent and an independent variable.

Answer 150

**Evidence-Based Medicine** t is also known as evidence-based practice. There will be several questions on the American Nurses Credentialing Center (ANCC) exam that will test your ability to sort and rate articles by the level of evidence.

Answer 151

**Meta-Analysis**

Answer 152

**Experimental Study**

Answer 153

**Opinions and Editorials**

Answer 154

**Cohort Study**

Answer 155

**Systematic Review**

Answer 156

**Case Report** **Case Series**

Answer 157

**Randomized Controlled Trial**

Answer 158

**Cochrane Reviews** The gold standard database and resource for EBM. These are systematic reviews (Cochrane Database of Systematic Reviews). The organization does not accept commercial or conflicted funding. Also known as the Cochrane Collaboration ([**www.cochrane.org**](http://www.cochrane.org/)). **MEDLINE** The U.S. National Library of Medicine (NLM) premier bibliographic database contains more than 26 million journal articles in the life sciences with a concentration in biomedicine. These articles are from 5,200 current biomedical journals published around the world. **PUBMED** This component of MEDLINE contains over 30 million citations of biomedical, medical, and other life science literature and abstracts. **CINAHL: Cumulative Index to Nursing and Allied Health Literature** The world’s largest source of full-text nursing and allied health journals (\>1,300 journals). Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete provides indexing of more than 4,000 journals.

Answer 159

A (best evidence), B, C, and D (poor evidence) Well-designed controlled experimental trials (double-blind RCTs) are considered to be grade A (or level 1) evidence.

Answer 160

1 = A 2 = C 3 = B

Answer 161

1 = B 2 = A 3 = C

Answer 162

**Confidence Interval** Confidence interval (CI) is a measure of the degree of certainty in a sampling method. For example, a 95% CI is a range of values that you can be 95% certain contains the true mean of the population. **Absolute Risk Reduction** Absolute risk reduction (ARR) is a measure of the difference between two different treatments in terms of their ability to reduce a particular outcome (e.g., myocardial infarction [MI], stroke). **Relative Risk Reduction** Relative risk reduction (RRR) is a measure of how much risk is reduced in the experimental group compared with the control group.

Answer 163

**Number Needed to Treat** Number of patients you have to treat to avoid one bad outcome (e.g., MI, stroke). For example, an NNT of seven means that it is necessary to treat seven patients to avoid one bad outcome. **Positive Predictive Value** The probability that a person with a positive screening test result has the disease. **Negative Predictive Value** The probability that a person with a negative test result does not have the disease.

Answer 164

**Active Immunity** Refers to immunity to a disease developed either through vaccination or by infection. **Passive Immunity** Refers to immunity to a disease after receiving antibodies (immunoglobins) from another host. For example, colostrum from breastfeeding gives the neonate antibodies from the mother. **Herd Immunity** Refers to resistance to a disease in a large number of people in the population, which is usually due to immunization programs. **Health** This refers to a state of complete physical, mental, and social well-being.

Answer 165

**Horizontal Transmission** Transmission of an infecting agent from one individual to another. For example, horizontal transmission of HIV and other STDs or infections occurs through sexual intercourse. **Vertical Transmission** Transmission of an infecting agent from mother to infant. Congenital infections from mother to infant can be passed through vertical transmission. Also, an HIV-positive mother who breastfeeds her infant can infect her infant with HIV through vertical transmission. **Endemic** This refers to a baseline level of a particular disease in a population. **Epidemic** Refers to the rapid increase of a disease in a population that involves a large number of people. **Pandemic** This is an epidemic that occurs over a very large area (several countries or continents). It involves a large proportion of the global population.

Answer 166

**Morbidity** This refers to an illness or any departure from physical and/or mental health. **Mortality** Death. **Infant Mortality** Refers to infant deaths per 100,000 live births. The leading cause of death in an infant’s first year of life is congenital malformations (including chromosomal abnormalities). **Sensitivity** Refers to the ability of a screening test to correctly identify a person *with* the disease. **Specificity** Refers to the ability of a screening test to correctly identify a person *without* the disease.

Answer 167

Memorize the definitions of sensitivity and specificity. * **Sensitivity:** Refers to the ability of a screening test to correctly identify a person *with* the disease. * **Specificity:** Refers to the ability of a screening test to correctly identify a person *without* the disease. Learn how to solve EBM “drag-and-drop” format questions (three or four questions). At the time of writing, only the ANCC exam has this format, although it is possible that the American Academy of Nurse Practitioners Certification Board (AANPCB) may use the question format in future exams. Learn the difference between endemic, epidemic, and pandemic. * **Endemic:** This refers to a baseline level of a particular disease in a population. * **Epidemic:** Refers to the rapid increase of a disease in a population that involves a large number of people. * **Pandemic:** This is an epidemic that occurs over a very large area (several countries or continents). It involves a large proportion of the global population.