D220 Study Guide – If you see a ** by something, then that was seen on a D220 test by SOMEONE.
According to some, there are handful of questions on the OA from the PA.
Access Levels- User can only see information that they access to. (CNA cannot see everything an RN can)
Administrative Safeguards of Electronic Health Information- Restricting access of all authorized users of
the EHR according to their position within the healthcare system
Admission-Transfer-Discharge (ADT) System - Classified under the hospitals' administrative info system. It’s
one foundational system that allows operational activities such as bed placement, transportation
coordination, room readiness, & the general coordination of services focused on the pt's phase of
movement. Tracks a pt's activities & location from admission to discharge.
American Recover & Reinvestment Act (ARRA) – Authorized INCENTIVE PAYMENTS to specific types of
hospitals & healthcare pros for adopting & using interoperable Health Information Technology & EHR’s.
ARRA provides economic stimuli & incentives for the adoption of EHRs.
Analytical Science – Answers 2 basic questions: What do I have? How much of it do I have? Environment,
pharmacy, safety & security, fraud detection, & healthcare diagnostics.
Asynchronous Applications – Pt-centered & allows consumers to participate in their own care by using
designated health technology to share health metrics & data w/ their healthcare provider via technology
(remote pt-monitoring - the use of devices to capture pt data at one location & then transmit it
electronically to healthcare pros at a different location, allowing the review of data for clinical decision-
making, i.e. MobileHealth).
**Audit Trails– Software that is used for detecting security violations, performance problems, & flaws.
Records activity by users & system. **Goal is to improve data integrity. An audit trail must contain the
name of the user, the application triggering the audit, the workstation, the specific document, a description
of event being audited, & the date/time to determine integrity of data.
Authentication – Action that verifies the authority of users to receive specified data.
Barcode Medication Administration - MANDATED BY FDA.
**Benchmark– Continual process of measuring services & practices against the toughest competitors in
the healthcare industry. Comparing the performance of an organization or clinician to others.
Big Data – Very large data sets beyond human capability to analyze or manage without the aid of
information technology. Considered data originating from very large data sets that help identify patterns &
trends. Big data cannot be managed without the use of technology to analyze its output. 5 properties-
Variety, velocity, volume, value, veracity.
Change Management/ Change Control- INVOLVES EMPLOYEES IN THE DECISION-MAKING PROCESS. Helps
prioritize limited resources & ensure systems standards are upheld. For example, medication
administration. SHOULD EXCLUDE SUBJECT MATTER EXPERTS WHEN DISCUSSING CHANGE CONTROL.
,**Clinical Decision Support System (CDSS)- Supports healthcare practitioners in making pt-care decisions
by integrating pt data w/ current clinical knowledge. Provides recommendations for care & must be
balanced w/ professional judgment, not used in place of it.
**Clinical Information System– Software used to access client data, plan, implement, & evaluate care. May
be specific to certain departments: lab, radiology, pharmacy, or pt populations. Provides pt centric
decision-making functionality to help guide a RN w/ decision-making. Acquires pt data so that healthcare
pros can review it & use information to deliver care.
Computer Literacy – Familiarity w/ the use of personal computers. The knowledge & ability to use
computers & technology efficiently. Computer literacy allows pts to interact w/ the internet.
Computerized Provider Order Entry (CPOE) – Prescriber’s decisions to enter orders & immediately share
orders w/ appropriate health pros who execute orders & departments that need to dispense, schedule, or
immediately deliver services to pts. CPOE can check for duplicate orders, alert departments to carry out
orders, & provide the status of each order.
**Confidentiality– Unspoken understanding that private information shared in a situation, in which a
relationship has been established for the purpose of treatment or delivery of services will remain
protected.
Configurability – Extent that a given software product can be adapted or changed to meet a user’s
preference.
Connected Health – Model or platform by which technology assisted healthcare is delivered between at
least 2 points, involving either synchronous or asynchronous exchange.
**Consolidated-Clinical Document Architecture (C-CDA) – Allows interoperability of health information
exchange between hospital systems.
Consumer Health Informatics (CHI) – Use of electronic information & communication to improve medical
outcomes & health-care decision making from the pt/consumer perspective. 3 barriers include: Privacy
issues, cognitive disabilities, low health literacy. Five examples: Personal Health Records, Telehealth, Mobile
Health, Games for Health, & Health 2.0. Telehealth is defined as healthcare at a distance using technology
that connects the pt & the clinician in real time.
**Continuity of Care Record (CCD) – Snapshot of a pt’s health & healthcare to provider who does not have
access to the person’s EHR.
Cumulative Index to Nursing & Allied Health Literature (CINAHL) – Primary database used for nursing
literature.
Data – Collection of #s, characters, or facts that are gathered according to some perceived need for
analysis.
**Data Analysis – The processing of data that identify trends & patterns of relationships.
, Data Information Knowledge Wisdom (DIKW) Framework - Data is most discrete component of the DIKW
framework. Mostly presented as discrete observations w/ little interpretation. Information is a continuum
of progressively developing & clustered data. Relations & interactions are not yet evident in information
alone. Knowledge is information that is processed & organized so relations & interactions are identified.
Wisdom is appropriate use of knowledge to manage & solve human problems. Wisdom includes ethics or
knowing why certain things/procedures should/should not be implemented in specific cases.
**Data Integrity – Ability to collect, store, retrieve correct, complete, & current data so that the data are
available to authorized users when needed. Can be compromised by incorrect entry of information, data
tampering, & system failure. Prevention by implementing security measures, audit trails, & having detailed
policies & procedures. Data integrity is the state wherein data are uncorrupted, accurate, & valid.
**Data Mining – Technique that look for hidden patterns & relationships in large groups of data using
software.
Data Scrubbing - Data scrubbing is the process by which incorrect, incomplete, duplicate, or improperly
formatted items are removed using special software designated for this purpose.
Data Warehouse – Provides a powerful method of managing & analyzing data.
**Decision Support Tool / Clinician Decision Support (CDS) / Decision Support System/Software (DDS) –
Software/app to help in human decision process. Software will look at the pt’s data & suggest appropriate
medical/nursing interventions. Can also trigger prompts/alerts to user. Requires human user input.
Decreases pt safety risk & increases positive pt outcomes (alerts for abnormal vs, lab results, med
contraindication, etc.) The right components of a CDS include a trigger, such as med order; input data, such
as lab values; intervention info, such as other options provided; & action step, such as action selected by
the Dr.
**Electronic Health Record (EHR) – Database of individual’s healthcare data during healthcare encounters.
It’s comprised of any pt data stored in electronic form. Electronic form/ database of a pt’s past medical
history, medical test, medications, images, etc. stored in electronic form. Enables many functions needed
to create & maintain EHRs. You will know if the EHR is successful if the customer’s needs were met.
**Electronic Medical Record (EMR) – Legal record created in hospitals & ambulatory settings of single
encounter/visit that is source of data for EHR. Brings together diagnostic & treatment info for an individual
in specific healthcare setting. ** Usually found in a physician’s office.
Electronic Medical Record Adoption Model (EMRAM) – Measures clinical outcomes, pt engagement, &
clinical use of EMR technology to strengthen organizational performance & health outcomes across pt
populations. Basically evaluates Health Information Systems.
Ergonomics – Scientific study of work & space, including details that impact productivity & health.
**Evidenced Based Practice (EBP) – Current, best evidence for pt care. Improves consistency & quality of
pt outcomes. Foundation of clinical practice & guides clinicians. Found in standing orders (ex. Sepsis
protocol).
According to some, there are handful of questions on the OA from the PA.
Access Levels- User can only see information that they access to. (CNA cannot see everything an RN can)
Administrative Safeguards of Electronic Health Information- Restricting access of all authorized users of
the EHR according to their position within the healthcare system
Admission-Transfer-Discharge (ADT) System - Classified under the hospitals' administrative info system. It’s
one foundational system that allows operational activities such as bed placement, transportation
coordination, room readiness, & the general coordination of services focused on the pt's phase of
movement. Tracks a pt's activities & location from admission to discharge.
American Recover & Reinvestment Act (ARRA) – Authorized INCENTIVE PAYMENTS to specific types of
hospitals & healthcare pros for adopting & using interoperable Health Information Technology & EHR’s.
ARRA provides economic stimuli & incentives for the adoption of EHRs.
Analytical Science – Answers 2 basic questions: What do I have? How much of it do I have? Environment,
pharmacy, safety & security, fraud detection, & healthcare diagnostics.
Asynchronous Applications – Pt-centered & allows consumers to participate in their own care by using
designated health technology to share health metrics & data w/ their healthcare provider via technology
(remote pt-monitoring - the use of devices to capture pt data at one location & then transmit it
electronically to healthcare pros at a different location, allowing the review of data for clinical decision-
making, i.e. MobileHealth).
**Audit Trails– Software that is used for detecting security violations, performance problems, & flaws.
Records activity by users & system. **Goal is to improve data integrity. An audit trail must contain the
name of the user, the application triggering the audit, the workstation, the specific document, a description
of event being audited, & the date/time to determine integrity of data.
Authentication – Action that verifies the authority of users to receive specified data.
Barcode Medication Administration - MANDATED BY FDA.
**Benchmark– Continual process of measuring services & practices against the toughest competitors in
the healthcare industry. Comparing the performance of an organization or clinician to others.
Big Data – Very large data sets beyond human capability to analyze or manage without the aid of
information technology. Considered data originating from very large data sets that help identify patterns &
trends. Big data cannot be managed without the use of technology to analyze its output. 5 properties-
Variety, velocity, volume, value, veracity.
Change Management/ Change Control- INVOLVES EMPLOYEES IN THE DECISION-MAKING PROCESS. Helps
prioritize limited resources & ensure systems standards are upheld. For example, medication
administration. SHOULD EXCLUDE SUBJECT MATTER EXPERTS WHEN DISCUSSING CHANGE CONTROL.
,**Clinical Decision Support System (CDSS)- Supports healthcare practitioners in making pt-care decisions
by integrating pt data w/ current clinical knowledge. Provides recommendations for care & must be
balanced w/ professional judgment, not used in place of it.
**Clinical Information System– Software used to access client data, plan, implement, & evaluate care. May
be specific to certain departments: lab, radiology, pharmacy, or pt populations. Provides pt centric
decision-making functionality to help guide a RN w/ decision-making. Acquires pt data so that healthcare
pros can review it & use information to deliver care.
Computer Literacy – Familiarity w/ the use of personal computers. The knowledge & ability to use
computers & technology efficiently. Computer literacy allows pts to interact w/ the internet.
Computerized Provider Order Entry (CPOE) – Prescriber’s decisions to enter orders & immediately share
orders w/ appropriate health pros who execute orders & departments that need to dispense, schedule, or
immediately deliver services to pts. CPOE can check for duplicate orders, alert departments to carry out
orders, & provide the status of each order.
**Confidentiality– Unspoken understanding that private information shared in a situation, in which a
relationship has been established for the purpose of treatment or delivery of services will remain
protected.
Configurability – Extent that a given software product can be adapted or changed to meet a user’s
preference.
Connected Health – Model or platform by which technology assisted healthcare is delivered between at
least 2 points, involving either synchronous or asynchronous exchange.
**Consolidated-Clinical Document Architecture (C-CDA) – Allows interoperability of health information
exchange between hospital systems.
Consumer Health Informatics (CHI) – Use of electronic information & communication to improve medical
outcomes & health-care decision making from the pt/consumer perspective. 3 barriers include: Privacy
issues, cognitive disabilities, low health literacy. Five examples: Personal Health Records, Telehealth, Mobile
Health, Games for Health, & Health 2.0. Telehealth is defined as healthcare at a distance using technology
that connects the pt & the clinician in real time.
**Continuity of Care Record (CCD) – Snapshot of a pt’s health & healthcare to provider who does not have
access to the person’s EHR.
Cumulative Index to Nursing & Allied Health Literature (CINAHL) – Primary database used for nursing
literature.
Data – Collection of #s, characters, or facts that are gathered according to some perceived need for
analysis.
**Data Analysis – The processing of data that identify trends & patterns of relationships.
, Data Information Knowledge Wisdom (DIKW) Framework - Data is most discrete component of the DIKW
framework. Mostly presented as discrete observations w/ little interpretation. Information is a continuum
of progressively developing & clustered data. Relations & interactions are not yet evident in information
alone. Knowledge is information that is processed & organized so relations & interactions are identified.
Wisdom is appropriate use of knowledge to manage & solve human problems. Wisdom includes ethics or
knowing why certain things/procedures should/should not be implemented in specific cases.
**Data Integrity – Ability to collect, store, retrieve correct, complete, & current data so that the data are
available to authorized users when needed. Can be compromised by incorrect entry of information, data
tampering, & system failure. Prevention by implementing security measures, audit trails, & having detailed
policies & procedures. Data integrity is the state wherein data are uncorrupted, accurate, & valid.
**Data Mining – Technique that look for hidden patterns & relationships in large groups of data using
software.
Data Scrubbing - Data scrubbing is the process by which incorrect, incomplete, duplicate, or improperly
formatted items are removed using special software designated for this purpose.
Data Warehouse – Provides a powerful method of managing & analyzing data.
**Decision Support Tool / Clinician Decision Support (CDS) / Decision Support System/Software (DDS) –
Software/app to help in human decision process. Software will look at the pt’s data & suggest appropriate
medical/nursing interventions. Can also trigger prompts/alerts to user. Requires human user input.
Decreases pt safety risk & increases positive pt outcomes (alerts for abnormal vs, lab results, med
contraindication, etc.) The right components of a CDS include a trigger, such as med order; input data, such
as lab values; intervention info, such as other options provided; & action step, such as action selected by
the Dr.
**Electronic Health Record (EHR) – Database of individual’s healthcare data during healthcare encounters.
It’s comprised of any pt data stored in electronic form. Electronic form/ database of a pt’s past medical
history, medical test, medications, images, etc. stored in electronic form. Enables many functions needed
to create & maintain EHRs. You will know if the EHR is successful if the customer’s needs were met.
**Electronic Medical Record (EMR) – Legal record created in hospitals & ambulatory settings of single
encounter/visit that is source of data for EHR. Brings together diagnostic & treatment info for an individual
in specific healthcare setting. ** Usually found in a physician’s office.
Electronic Medical Record Adoption Model (EMRAM) – Measures clinical outcomes, pt engagement, &
clinical use of EMR technology to strengthen organizational performance & health outcomes across pt
populations. Basically evaluates Health Information Systems.
Ergonomics – Scientific study of work & space, including details that impact productivity & health.
**Evidenced Based Practice (EBP) – Current, best evidence for pt care. Improves consistency & quality of
pt outcomes. Foundation of clinical practice & guides clinicians. Found in standing orders (ex. Sepsis
protocol).
