Quizlet Flashcards
Which information in an electronic medical record (EMP) helps a nurse plan & manage a patient's post- operative care after open-heart surgery
Provider order
Which information in a patient's electronic medical record (EMA), in addition to the nursing flowsheets & provider orders, helps a nurse plan & manage fluctuations in blood glucose levels
MAR
A nurse is planning the care for a patient admitted to the hospital with COVID-19 Which list of information in the electronic medical record (EMR) will help the nurse plan the care for this patient
The patient's laboratory results over the last 72 hours.
Which clinical note type is exempt from being shared with patients according to the United States Core Data for Interoperability (USC DI) standards
Psychotherapy notes
A patient is being transferred to another hospital, however, the hospital he is being transferred to does not have access to the Electronic Health Record (EHR) since they use EPIC. How will they receive his Electronic Health Record (EHR)?
Continuity care record from AMR
Operating room (OR) staff are reliant upon a manual whiteboard for patient tracking. Recently, surgeons have complained that the turnaround time between surgical cases has increased & blame the manual tracking system. An informatics nurse recommends expanding the use of the existing surgical information system (SIS). Which resolution can improve this workflow issue?
Radiofrequency identification (RFID) in patient labels
What is an effective way to reduce the risk of access to electronic protected health information (ePHI) by unauthorized users
Make sure all the users adhere to the security & confidential policy set forth by the facility.
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
Which act in 2009 did Meaningful Use (MU) originate
American Recovery & Reinvestment Act (ARRA) act in 2009
What is the intent of the Clinical Decision Support (CDS) System
Providing clinicians with knowledge & person-specific information.
Which government organization oversees the meaningful use program
CMS (Centers for Medicare and Medicaid Services
A Nursing Innovator & a medsurg nurse want to capture how many patients were seen in a day of 24 hours, how would they best see this
Flowsheet
Process for discovering root causes of problems & ID the solution
Root cause analysis
What should providers have on their personal mobile devices to protect them from sharing information when stolen?
Authentication & encryption
Which area of the Electronic Health Record (EHR) is used to guide a nurse on the task that needs to be completed during the shift
Workflow
How does the health information exchange (HIE) improve interoperability within a healthcare organization
It allows patient information to be accessible despite where the patient is receiving care.
Which statement defines electronic protected health information (ePHI)
It is the information used to specifically identify an individual.
In a healthcare setting, there is resistance to using a new Electronic Health Record (EHR). The staff insists the prior system was much faster than navigating this new Electronic Health Record (EHR). Which method should be used to motivate staff to adopt this Electronic Health Record (EHR)
Involve staff in the implementation process.
An informatics nurse is developing a web-based application for patient care. Which statement accurately describes the internet?
An unregulated network of networks
What represents privacy & security risks for telehealth technology?
Patients have the option to use the speakerphone in the telehealth apps.
A restraint committee has been assembled to oversee the need proper usage of restraints. Which data element would this committee find least useful in this report?
Patient allergy history
What is a structured method used to analyze serious adverse events?
A root cause analysis (RCA)
Which form allows stored information in an Electronic Health Record (EHR) to be instantly searched, retrieved, combined, & reported in different ways?
Text data
Why was Barcode Medication Administration (BCMA) adopted by healthcare facilities
To prevent medication administration errors
MRSA
Contact precautions
Which info in Electronic Medical Records will help nurses manage post-op care for appendectomy
Doctor’s orders
The act that recognizes patients need more power in their healthcare, & access to information is key to making that happen or What act puts patients in charge of their healthcare records?
21st Century Cures Act
Tapping badge
Improves documentation time.
Action that demonstrates data mining to improve patient outcomes
HbA1c
What to do when Clinical Decision Support (CDS) System is ignored
Educate staff on the importance.
Spouse requests patient's medical records
Refer the family member to medical records.
Comparing infection rates across the states
Bar graph
Promoting the adoption & implementation of telehealth programs
Advocacy
Mom calls asking for the child's info that was seen at the clinic
Clinic is unable to provide the medical records.
Metrics related to stroke care & compare them across the country in a presentation
Benchmarking
Confirming data accuracy or Analyzing a single piece of data in multiple ways
Triangulation
What is included in meaningful use
Use of electronic prescribing
What is the goal of the Health Information Exchange
To allow insurance companies & providers to be able to share data
Groups at risk for decreased health literacy?
Elderly
The main way to keep HIPPA compliance?
Passwords
The element that is PHI
DOB
The best method of Electronic Medical Record charting for nursing? Or Data Entry fields
Cascading
Physical taking care of a patient whose established care is somewhere else talking about Health Information Exchange
Query-based
When can you get notes from the provider quickly?
Health Information Exchange, Query-based transfer.
Nurse wants to optimize EH software with the goal of decreasing documentation time
Surveys
What would be the causes to put someone in isolation?
MRSA, Influenza, TB, Covid
Universal precautions approach to health literacy
Treating all patients as if they are at risk of not understanding health information and speaking to patients in language-appropriate terminology.
How to start an admission process when extremely busy?
Checklist
Data visualization of oncology patient length of stays
Line graph
Define predictive modeling/analytics
Uses past & current data to forecast the likelihood that an event will occur.
What data source is used to track specific diseases & conditions
Disease surveillance
Non-maleficence & fidelity, promote accuracy & integrity.
Fundamental principles
HIPPA stands for and what year did it form
Health Insurance Portability & Accountability Act 1996
What year did Hitech Act form
2009
Two nurses are in the cafeteria talking about lab reports & they commit HIPAA violations what is the action
Fines
Medication alert pops up, what system is alerting
Clinical Decision Support (CDS) System
Monitor the patient's glucose level you need
Nurse flow sheets
What is the barrier to using biometrics
Financial
During which phase of the systems development life cycle should a system be activated to effectively be used by end users
Implementation
Homeless man IV drug user
Find in the EMR which information helps you put him in isolation.
Treatment of patients related to blood pressure measures
Medication administration
When does discharge planning
Starts on admission
Single event & doing root cause analysis
Fishbone
Discharge teaching patient with diabetes
Important what the time of day
Stroke patient & analysis
Statistical, fishbone
D/C teaching
The 5th-grade level starts on admission, time of day, and increase font size.
Rapid dictation advantages of template-based charting
They are available immediately and eliminate human errors & more accurate documentation
A high number of data-entry fields in electronic health records can be overwhelming for staff & make it difficult to find where information should be documented. Which informatics solution could solve this problem?
Cascading documentation
How can informatics be used to assess a person’s health literacy
Informatics can evaluate the current state & determine the resources needed to determine a patient’s level of understanding.
Pie
Percentages chart
Bar graph
Nouns
Ensures the app still functions as expected after an update or change in improvement.
Regression testing
Life insurance wants records
Don’t release
HIPAA
Name, birthdate/year, test results, and lab results are protected.
Nurse finds 100 errors in coding
AHIMA & report to nurse manager
Glucose stabilizing & Blood Pressure stabilizing
Trending graph
Clean & accurate, quality of care, can be used to evaluate patient safety, and quality performance, measure & compare services, improve performance, sets standards of excellence, identifies learning gaps (pt falls)
Benchmark
Covid graphing
Scatterplot
Statistical analysis
Stroke patient
Review ICU fall risk
Different reviewer's conduction research
Benefit of Internet/externet
Improve communication & teamwork
Ethical/legal issue with rural hospital & tele-radiology
State licensing issue
What is an example of the benefit of MD using Computerized Provider Order Entry (CPOE) & DSS
Alerts when ordering Viagra (sildenafil) when patient is taking a cardiac med
Staff is resistance to Tele-ICU. What are the benefits
Resources and expertise
HIPAA violations
Civil monetary fines
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
Which act in 2009 did MU originate?
ARRA act in 2009
Which two technologies support the standardization of healthcare data?
HL7 (Health Level 7) & DICOM
An informatics nurse & an ER nurse are conducting an analysis of a patient admission form the ER. Which tool should these nurses use for a process analysis?
SWOT
Which government agency recommended to use of bar code medication administration?
FDA
A laboratory manager requested a report of all patients that had a blood glucose greater than 400mg/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
Process for discovering root causes of problems & ID the solution?
Root cause analysis
Which is a physician’s clinical informatics assessment?
Vital signs
Which EHR challenge can a nurse informaticist help support & change?
Analyzing and redesigning workflows
What describes the goal of EHR incentive programs, such as meaningful use?
To promote the achievement of quality, safety, & efficiency measures
What is the role of the informatics nurse working with EHR?
To improve patient safety
Health systems can be inoperable with other health systems. What are 2 barrier that prevent interoperability
Data blocking, interface cost
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.
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
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
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
Pt discharge, information planning-
History & physical notes about the reason the pt is admitted anyways
Pt with scabies
Crusted rash, CDC says that the diagnosis of scabies is by physical examination of skin
Pts come in complaining of the same S/Sx
Patient demographics
COPD pt planning care
Complete health history
HIPAA violation fine or What is the dollar amount price range for a HIPPA fine per violation (lowest to highest amount).
$100-50,000
Act that recognizes pts need more power in their healthcare, & access to information is key to making that happen?
21st Century Cures Act
Patient engagement benefits
Costs decrease, lower readmission rate, improved pt recovery times, increase pt empowerment
Which pt are most able to engage in their care?
Whose pain is under control or good night rest
Nurse is giving Pt education over new medication?
Ask pt to repeat info—teach backs
Hospital employee falls. Their manager calls & wants an update
Nurse should not provide info
Electronically capture pt VS without manually entering
Biomedical device integration
HIS system for pt to manage their own stuff?
The app
What to do when CDSS is ignored
Educate staff on the importance
A pt employer calls asking for information on pt that got hurt at work?
Ask employer to submit a signed agreement to protect the pt info
What is the best practices for HIPAA
Require password
Hiker information given to newspaper?
Hospital violates hipaa because they did not follow their guidelines
Pt records moved from notes to checkboxes
They reduce clinical documentation time
Gap analysis?
Transition to a new HER
What does a focus group do?
Gathering uses to discuss
What is a peripheral biometric device?
High bp monitoring
What is the goal of Health Information Exchange?
To allow insurance companies & providers to be able to share data
How would an informatics nurse best evaluate other nurses;’ opinions on technology?
Survey
Barcoding scanning. How it affects inventory with pharmacy?
Alters ordering & information data
What should a nurse recommend to promote nurse to pt interactions?
Encourage pt to eliminate personal technology to increase their attention
Role of an informatics nurse specialist is the knowledge & application of state & federal laws. Which role falls outside the scope of practice?
Enforce operational procedures
Situation where nurse carries out an HIE?
NP reviews pt records/read dx test results from remote facility
A blood pressure cuff or peripheral device linked to the computer or health system is what kind of technology?
Biomedical device integration
Data visualization of oncology pt length of stays?
Line graph
Health literacy universal precaution-AHRQ?
5th grade reading level is the best
What is a fishbone diagram & what benefit does it provide?
A tool for analyzing the organizational processes & its effectiveness. Helps team members visually diagram a problem or conditions root causes, allowing them to truly diagnose the problem rather than focusing on symptoms
What legislation provides more rigorous enforcement of HIPPA & requires notification of breaches & allow pt access to their electronic records?
HIPPA Breach notification Rule, US dept of health & human services (HHS) & Office for Civil rights (OCR) is responsible for enforcing HIPAA
