Nursing Informatics Exam 229 Questions with Verified Answers,100% CORRECT,100% CORRECT

Nursing Informatics Exam 229 Questions with Verified Answers Information theory - CORRECT ANSWER Processing data to produce information and, in combination with knowledge and wisdom, using information to provide care Change Theory - CORRECT ANSWER unfreezing -->moving-->refreezing Systems Theory - CORRECT ANSWER interaction among parts Behaviorism - CORRECT ANSWER desired behaviors are reinforced Constructivism - CORRECT ANSWER reinterpret the world to fit new situations Adult learning - CORRECT ANSWER learn by doing, must know why they need to learn and value of learning nursing informatics is a combination of what? - CORRECT ANSWER -nursing science: Professional Nursing principles and practices in the delivery and management of patient care -computer science: Data storage, management, retrieval, and processing -information science: What data are needed; how to obtain it, and how to communicate that data as useable information nursing informatics definition - CORRECT ANSWER A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge and wisdom in nursing practice. Institute of Medicine Report - 2001 on information technology - CORRECT ANSWER -There must be a renewed national commitment to building an information infrastructure to support health care delivery, consumer health, quality measurement and improvement, public accountability, clinical and health services research, and clinical education. -This commitment should lead to the elimination of most handwritten clinical data by 2010. Health Information Technology (Dept. of HHS) Vision: - CORRECT ANSWER -Medical information follows consumers; consumer-centered care -Consumers choose physicians and hospitals based on known performance results -Clinicians access medical history, computerized ordering systems, and electronic reminders -Quality performance initiatives drive quality-based competition -Clinical research and post-marketing surveillance are fostered American Recovery and Reinvestment Act (ARRA) - CORRECT ANSWER -Financial incentives -Adopt electronic records -"Meaningful Use" -Medicare EHR Incentive Program -Hospitals and individual providers -Begin by 2012 -In 2015, penalty if unable to show meaningful use -Includes provider order entry -Health Information Exchanges (shared EMRs) How can Informatics improve Patient Safety? - CORRECT ANSWER -Improves legibility -Provides greater continuity of care -Supports safe medication practices -Improves nursing workflow; eliminates redundant documentation -Provides access to up-to-date, accurate data for informed decision-making -Decision support based on assessment data Using Decision Support in Practice - CORRECT ANSWER -Emphasis on Evidence-Based Practice (EBP) - match patient data with a specific knowledge base to generate evidence-based recommendations -Assists clinicians with varying levels of clinical experience (novice vs. expert) -Reduces decisions that are made based on incomplete or misinterpreted information Documentation Principles - CORRECT ANSWER -Reflects current standards of practice and level of quality care -Regulations/Standards -Contents of electronic and written record -Purposes of records -Confidentiality/ HIPAA Confidentiality in the Workplace - CORRECT ANSWER -Don't share information in public areas (elevators, cafeterias, hallways, public restrooms) -Don't share information with anyone not directly involved with the patient's care. -Patient may not want family to know details of care. -Don't look up friends, family, celebrities or other patients on other floors. -Don't speak of the patients outside of the hospital to family, friends, neighbors, etc Rules to help keep the record top secret! - CORRECT ANSWER -Timely log off -Frequently change password -Don't share passwords or codes with ANYONE! Methods of Recording - CORRECT ANSWER -Narrative -PIE: Problem, intervention, evaluation -SOAP: Subjective, objective, assessment, plan -Problem-Oriented Medical Record (POMR) -Case management/Critical pathways -Home Health - Medicare OASIS -Nursing Homes - Medicare MDS -Charting by Exception (CBE) Charting by Exception - CORRECT ANSWER -Concise and time-saving -Emphasizes abnormal findings -Identifies trends in care -Requires clearly defined standards (WDL) -Assumes all standards met unless otherwise stated (WDL Except) -Requires thorough descriptions when condition changes Guidelines for Quality Documentation and Reporting - CORRECT ANSWER Factual: Legal -- Libel (written) and slander (spoken) Accurate and Complete Current Organized Factual - CORRECT ANSWER Descriptive, objective information -Furrowed brow; states "I feel nervous about the surgery" Describe what your senses tell you Avoid Vague terms Appears, seems, apparently Opinions Patient seems anxious Legal - CORRECT ANSWER Do Not Make comments about other HCT members Dr. Green was late Chart for others (note exception...) RN Smith gave the med Chart what others did or did not do The PCT failed to give the bath Chart statements that can be libelous The patient is angry Accurate and Complete - CORRECT ANSWER Use of exact measurements Client drank adequate amount of water (vague) Intake, 360 ml water Concise, clear, easy to understand Large wound healing well (vague) LUQ abdominal wound 5 cm in length without redness, drainage or edema Avoid unnecessary words & irrelevant details Use accepted abbreviations Accurate Written Documentation - CORRECT ANSWER Spelling / Legible Dysphagia, dysphasia Dram, gram Digoxin, digitoxin Black Pen Not pencil Date/time and signature/status authentication 06/1/12, 2330, Julie Spencer, RN. Current - CORRECT ANSWER Timely entries Write (enter) it when you do it Record near bedside (point-of-care) Electronic documentation Military time Late entries Time documented and time of occurrence Organized - CORRECT ANSWER Logical order Assessment Interventions Client response Example: Patient reports headache at a level of 7, on the zero to ten scale. Medicated with 600 mg Ibuprofen at 1130. At 1230, patient reports headache is completely resolved, pain score now zero. Incident Report - CORRECT ANSWER Non-discoverable Responsible person Witnesses Risk Management Nursing Manager Not in patient medical record No copy to patient/family Objective, factual, no opinions Legal Risks of Computerized Documentation - CORRECT ANSWER Passwords Strength Frequently changed Private, not shared Close the chart Confidentiality Right to access Who Identification What can happen when the rules are broken? - CORRECT ANSWER Lawsuits Loss of job or license Suspension No matter what, there will be a penalty. The document is no longer credible. Correcting Errors - CORRECT ANSWER Hand written One line through the error Write Error above it Initial and date the error Electronic Remove inaccurate documentation "c" remains Add corrected entry Optional "note" Presidents informatics thecnology advisory committee (PITAC) - CORRECT ANSWER was created to support for greater use of informatics provide a brief definition of clinical decision support system - CORRECT ANSWER health information technology improving the success in clinical decision making what are some examples of decision support? - CORRECT ANSWER -for evaluation of treatment alternatives for supra ventricular and ventricular arrhythmia's -admission after surgery/pacu -there are a lot of scenarios that decision support can help what does the term 'alert fatigue' mean and how can it impact decision support systems? - CORRECT ANSWER -when staff get so used to alerts that they don't even notice them -the computer system could help them prioritize the needs of patients based on actual NEED! but the negative is that nurses tend to make their own priorities based on work flow what are the benefits and limitations of nursing clinical decision support system? - CORRECT ANSWER Nurses spend up to 50% documenting, computerization is essential-time saving, cost effective PROS: reduce data redundancy, enforce quality standards, interface easily with bedside and other technologies CONS: lack of integration and external connectivity that would enable sharing info, do not support clinical decision making provide a brief definition of just culture - CORRECT ANSWER an organizational culture revolved around safety, accountability, acceptance, responsibility Discuss examples of barriers to a jus culture; how can these barriers be reduced? - CORRECT ANSWER -human factors--long standing beliefs, inconsistent way to report errors, fear of retribution from others -educate staff on a just culture, reward positive efforts how can informatics be used to monitor errors and support a just culture? - CORRECT ANSWER develop a computer system that will handle documenting errors give us an idea of the scope of medication error problems in the US - CORRECT ANSWER -7,000 people die in America yearly from med errors -medication errors are the 2nd most frequent type of all medical errors how does BCMA(Bar Code Medication Administration) contribute to patient safety - CORRECT ANSWER accurately confirms the 5 patient rights 1. correct pt 2. correct meds 3. correct time 4. correct dose 5. correct route what are some of the limitations of BCMA - CORRECT ANSWER -it can slow down the process in emergency situations -technology is not 100% reliable -over dependence -there is always a way to override the system and that can be abused describe types of nursing reports that could help monitor the use of BCMA technology. - CORRECT ANSWER -outcome reports -# of scanner failures -how many people are complying -are there certain barcodes that don't work define tele nursing and describe how it occurs - CORRECT ANSWER nursing at a distance describe at least 2 examples of patient assessments that may be accomplished using tele nursing - CORRECT ANSWER -monitored by satellite -telephone education -research over video conference what are the benefits and limitations of telenursing - CORRECT ANSWER PROS: saves money, remote data collection, family involvement CONS: difficult for elderly pr people who don't like the idea of learning or those without access to communication, nurses can't have hands on in the process what is the Leapfrog Group and how can they help hospitals that us CPOE? - CORRECT ANSWER -a group that yeps monitor how hospitals do with CPOE -help give feedback to hospitals they monitor How can CPOE contribute to patient safety? - CORRECT ANSWER the more compliance with leap forms standards allows less room for mistakes what are potential barriers to CPOE - CORRECT ANSWER -your knowledge of a new system can inhibit correct use -very expensive what are some ways to make sure a CPOE system meets the needs of staff? - CORRECT ANSWER -test all systems at the beginning of shifts to avoid glitches -make sure that staff fully understand the system -ask staff what they need what is CPOE - CORRECT ANSWER computerized provider order entry define bioinformatics - CORRECT ANSWER computation of analysis of and interpretation of biological data how did the human genome project utilize bioinformatics - CORRECT ANSWER stored the data on computer systems and made it public for all to see describe an example of data about a specific disease or condition that could b contained in a bioinformatics database - CORRECT ANSWER -diabetes -HPN -arteriole sclerosis -cancer cyberchondriac - CORRECT ANSWER a person who reads health or medical information on the internet and develops imaginary physical symptoms and ailments health numeracy skill - CORRECT ANSWER being able to understand numbers in nursing like lab values, pain level, nutrition, vital signs, dosages american association of colleges of nursing (AACN) - CORRECT ANSWER list of core competencies includes many recommendations in the area of information and healthcare technologies, such as the use of information and communication technologies, the use of ethics in the application of technology, and the enhancement of ones knowledge using information technologies American Nurses Association (ANA) - CORRECT ANSWER ANA, ANA - Prof. org. for RNs in the US. Founded in 1800's. Primary mission is to be involved in public education, clinical nursing standards, and lobbying of state and federal lawmakers to advance the profession of nursing. Addresses ethics, public policy and the economic and general welfare of nurses. Data - CORRECT ANSWER Facts and statistics collected together for reference or analysis deidentified data - CORRECT ANSWER information shared outside of an agency or with those who don't need to have personal information about a patient it electronic numerical integrator and computer (ENIAC) - CORRECT ANSWER one of the first electronic digital computers in the United States—was commissioned by the U.S. Army and first installed at the University of Pennsylvania in Philadelphia factual database - CORRECT ANSWER replace reference books with searchable and updatable online information genomics - CORRECT ANSWER Is the study and comparison of genomes both within and across species. healthcare informatics - CORRECT ANSWER the management of information, by using cognitive skills and the computer health information technology - CORRECT ANSWER technology that is used to record, store and manage patient health care information informatics - CORRECT ANSWER information management, not computers in healthcare information literacy - CORRECT ANSWER Understanding the role of information in generating and using business intelligence information technology - CORRECT ANSWER Any computer-based tool that people use to work with information & support the information-processing needs of an organization. institute of medicine (IOM) - CORRECT ANSWER This is a nonproft organization that provides advice to lawmakers and the public about health issues. listserv - CORRECT ANSWER an email discussion list that has participants who discuss various aspects of a topic such as informatics national league for nursing (NLN) - CORRECT ANSWER a national organization for nurses that is composed of nurses and consumers and was created in 1952 with the closure of the National Organization for Public Health Nursing and other professional nursing organizations nursing informatics - CORRECT ANSWER the science of using computer information systems in the practice of nursing presidents information technology advisory committee (PITAC) - CORRECT ANSWER Authorized by Congress under the High-Performance Computing Act of 1991 (P.L. 102-194) and the Next Generation Internet Act of 1998 (P.L. 105-305) as a Federal Advisory Committee. The committee provides the President, Congress, and the Federal agencies involved in networking and information technology research and development with expert, independent advice on maintaining America's preeminence in advanced information technologies. problem-oriented medical information system (PROMIS) - CORRECT ANSWER first attempt at providing a total, integrated system that covered all aspects of health care, including patient treatment problem oriented medical record (POMR) - CORRECT ANSWER Data is arranged according to the problems of the patient, members of the health care team add to the problem list, a plan is then formulated for each actual and potential problem protocols - CORRECT ANSWER are written plans that detail the nursing activities to be executed in specific situations quality and safety education for nurses (QSEN) - CORRECT ANSWER A national program that addresses the challange of preparing future nurses with the knowledge, skills, and attitudes (KSA) necessary to continually improve the quality and safety of the health care systems in which they work. secondary data - CORRECT ANSWER Data previously collected for any purpose other than the one at hand standardization - CORRECT ANSWER Defining meaningful scores by comparison with the performance of a pretested group. technology informatics guiding educational reform (TIGER) - CORRECT ANSWER Began in 2006; Focuses on designing plans to enhance the nurse's ability to use electronic health records to improve health care delivery, have more nurses engaged in national health care info. systems infrastructure and speed the adoption of technology that can enhance health care safety and effectiveness advanced search - CORRECT ANSWER Allows additional search options and exclusions to be applied, refining the results that are returned. evidence based care - CORRECT ANSWER Integrates published research, clinical experience, and patient preference federated search - CORRECT ANSWER searching more then one database at a time index - CORRECT ANSWER A directory of contents keywords - CORRECT ANSWER Important words found in a document. Keywords can be used to classify a document. knowledge-based database - CORRECT ANSWER indexes published literure, focuses on areas of health sciences, business, history, government, law and ethics medical subject heading (MeSH) - CORRECT ANSWER MESH - a controlled vocabulary developed by the National Library of Medicine (NLM) used for indexing articles in Index Medicus and now on MedLine meta-analysis - CORRECT ANSWER A procedure for statistically combining the results of many different research studies personal reference manager - CORRECT ANSWER software for scholars and authors to use for recording and utilising bibliographic citations randomized controlled trials - CORRECT ANSWER An experiment that delivers an intervention or treatment; it is the strongest design to support cause and effect relationships because subjects are randomly assigned to control and experimental groups. research practice gap - CORRECT ANSWER discrepancy between research on effective clinical practice and the direct care provided to patients seminal work - CORRECT ANSWER A classic work of research literature that is more than 5 years old and is marked by its uniqueness and contribution to professional knowledge. subject heading - CORRECT ANSWER A word or phrase identifying the content of an item being cataloged and used as an access point; a term from an authorized list of terms to be used as access points, called a Descriptor. systematic review - CORRECT ANSWER designed to reduce three ties of bias inherent in individual research studies: selection, indexing, and publication confidentiality - CORRECT ANSWER A relationship where the foundation is safety, trust & respect for the client to relax, open, release & heal is? de-identified data - CORRECT ANSWER can not be associated to a person. NOT subject to HIPAA rules. removal of name, age, dob, address, insurance, etc E-encounter - CORRECT ANSWER a two way exchange of healthcare information between a healthcare provider and a client/patient electronic health record - CORRECT ANSWER EHR, A patient record that is created using a computer with software. A template is brought up and by answering a series of questions data are entered. electronic medical record - CORRECT ANSWER An electronic record of patient health information generated by one or more encounters in any care delivery setting encryption - CORRECT ANSWER Process of converting readable data into unreadable characters to prevent unauthorized access. flash drive - CORRECT ANSWER portable storage device health insurance portability and accountability act (HIPAA) - CORRECT ANSWER HIPPA is an administrative function of handling client records and confidential health insurance information. The purpose of act is to ensure confidentiality of these records is maintained and the client's privacy is upheld interoperable - CORRECT ANSWER The capability of a system to work with or use the parts or equipment of another system national health information network (NHIN) - CORRECT ANSWER Offers a referral source for health information and has a Health Information Resource Database privacy - CORRECT ANSWER Freedom from unauthorized intrusion. readability - CORRECT ANSWER The difficulty level of written materials smart card - CORRECT ANSWER a plastic card containing a microprocessor that enables the holder to perform operations requiring data that is stored in the microprocessor unique patient identifier - CORRECT ANSWER The key data element for linking data about an individual who is seen in a variety of settings is the: USB port - CORRECT ANSWER A standard cable connection interface on personal computers and consumer electronics. accessibility - CORRECT ANSWER The relative ease with which a destination may be reached from some other place alt tag - CORRECT ANSWER text alternatives braille reader - CORRECT ANSWER a device that is placed near or under the keyboard. user then uses their fingers to "read" the information broadband - CORRECT ANSWER A high-speed Internet connection that is always connected consumer informatics - CORRECT ANSWER Branch of medical informatics that studies the use of electronic information and communication to improve medical outcomes and the health care decision-making process from the patient/consumer perspective dial up connection - CORRECT ANSWER A connection that uses a phone line to establish a temporary internet connection extranet - CORRECT ANSWER A private electronic network that links a company with its suppliers and customers flash animation - CORRECT ANSWER Multimedia technology that enhances Web graphics health literacy - CORRECT ANSWER a person's capacity to learn about and understand basic health information and services and use these resources to promote his or her health and wellness health numeracy - CORRECT ANSWER the skills necessary to understand and use quantitative health information HEDIS - CORRECT ANSWER healthcare effectiveness data and information set provides information to consumers and employers that allows them to compare the performance of health plans with other plans and to national or regional benchmarks. image map - CORRECT ANSWER a region on a web page that contains one or more hot spots navigation bar - CORRECT ANSWER a set of hyperlinks that give users a way to display the different pages in a website NCQA - CORRECT ANSWER national committee for quality assurance private nonprofit corporation dedicated to improving health quality patient portal - CORRECT ANSWER secure website that enables communication between patients and health care providers for tasks such as scheduling, completing registration forms, and making payments plug in - CORRECT ANSWER A hardware or software application that adds a specific feature to a browser. screen reader - CORRECT ANSWER a device used by individuals with visual impairments to convert written text on a computer monitor to spoken words support group - CORRECT ANSWER A group comprised of people who come together to bolster each other by providing encouragement, honest feedback, and a safe environment for expressing deeply personal feelings about a problem common to the members. URL - CORRECT ANSWER A location or address identifying where documents can be found on the Internet; a Web address usability - CORRECT ANSWER The degree to which a system is easy to learn and efficient and satisfying to use active RFID - CORRECT ANSWER an RFID tag that has batteries and can be read tens of feet away. aggregated data - CORRECT ANSWER results for the entire sample in a study, rather than for any individual subject or participant certification commission for healthcare information technology (CCHIT) - CORRECT ANSWER -a nonprofit organization whose mission is to accelerate the adoption of HIT. clinical decision support system (CDSS) - CORRECT ANSWER * Electronic system that provides structured guidance based on pat reduces the patient-specific input clinical documentation - CORRECT ANSWER What is the most important component of the health record? closed-loop safe medication administration - CORRECT ANSWER the right patient received the right medication electronic medication administration record (eMAR) - CORRECT ANSWER This part of the EHR automates many of the medication administration process in a facility. enterprise - CORRECT ANSWER A business organization in such areas as shipping, mining, railroads, or factories. health information technology (HIT) progressive disclosure - CORRECT ANSWER technology that is used to record, store and manage patient health care information integrated interface - CORRECT ANSWER the selection of a collection of HISs that are already interfaced mission critical - CORRECT ANSWER any process that is crucial to an organization passive RFID - CORRECT ANSWER less expensive, derive power from the radio signal sent by the reader , travel no more than few inches to 4 ft. physician quality report initiative (PQRI) - CORRECT ANSWER establishes a financial incentive for eligible professionals who participate in a voluntary quality reporting program picture archiving and communication system(PACS) - CORRECT ANSWER Computers or networks dedicated to the storage, retrieval, distribution, and presentation of images. positive patient identifier (PPID) - CORRECT ANSWER is used to insure that you are dealing with the right patient; id bracelets can be used as well as active and passive RFIDs radio frequency identifier (RFID) - CORRECT ANSWER System of tags which contain data that can be read from a distance using radio waves. biometrics - CORRECT ANSWER the use of physiological characteristics such as iris or retinal scan, fingerprint, or voice print that is presumably unique to the particular person data security - CORRECT ANSWER Method of ensuring that data is correct, safe and cannot be read or changed by those who have no right to access it. interoperability - CORRECT ANSWER Ability of systems to communicate by exchanging data or services. intangibles - CORRECT ANSWER things that cannot be realized or defined login - CORRECT ANSWER A process by which you gain access to a computer by giving it your username and password. password - CORRECT ANSWER A safeguard for access to a computer or computer program. return on investment (ROI) - CORRECT ANSWER expectation that an effort expended will results in a payoff/ gain. single sign on - CORRECT ANSWER This allows sign on to multiple related but independent software systems. spear phishing - CORRECT ANSWER Phishing that targets only specific users stark rules - CORRECT ANSWER physician self referral law prevents medicare fraud strategic planning - CORRECT ANSWER Identifying an organization's long-term goals & determining best approach to achieving those goals tangibles - CORRECT ANSWER The appearance of physical facilities, equipment, personnel, and communication materials. unintended consequences - CORRECT ANSWER The unexpected and unplanned results of a decision or action. voice recognition - CORRECT ANSWER Input devices used to "speak" commands into the computer and to enter text. workflow redesign - CORRECT ANSWER process is focused on making relatively small (not widespread) changes to an existing process biometric garment - CORRECT ANSWER wearable technology that will allow for a proactive approach where symptoms are identified early before problems develop e-intensive care - CORRECT ANSWER remote monitoring of critical care patients robotics - CORRECT ANSWER Mechanical devices programmed to do routine tasks. store and forward (S&F) - CORRECT ANSWER two way communication tele health - CORRECT ANSWER telephone nursing and health counseling telehomecare - CORRECT ANSWER monitoring and delivery of healthcare in the patient's home instead of the provider's work setting. telemental health - CORRECT ANSWER used to deliver psychiatric healthcare; reports suggest it is just as comparable to face to face psychiatric care. Used to provide care to people suffering from domestic violence in poorer areas. telepresence - CORRECT ANSWER Tech that allows a person to give the appearance of being present at a location other than his or her true location teletrauma - CORRECT ANSWER Used to obtain opinions and advice from trauma care experts; Used a lot in rural hospitals. Also has been used in parts of the world torn by violence and war; has shown a lot of promising outcomes Health policy may at times contribute to negative trends. Certain aspects of U.S. health policy have been blamed for creating or contributing to some of the health problems. Which of the following are associated with wayward policies? Select all that apply - CORRECT ANSWER a. Lack of clinical and administrative standardization b. Fragmented care c. Unequal access to care d. Turning health problems into marketing opportunities e. Failure to curtail costs for services Health information technology can be seen as a tool to aid the health care reform process through which of the following? - CORRECT ANSWER Recognition of its potential to improve with safety and efficiency of health care delivery Which of the following laws, signed by President Clinton in 2000, gives electronic signatures the same legal status as handwritten signatures? - CORRECT ANSWER The Electronic Signatures in Global and National Commerce Act Which act makes several significant changes to the current HIPPA Security and Privacy Rules and provides funds and incentives to increase the use of electronic health records (EHRs) by physicians and hospitals who meet eligibility criteria? - CORRECT ANSWER Health Information Technology for Economic and Clinical Health Act (HITECH) To receive financial incentives, hospitals and physician offices must meet designated criteria established by which organization - CORRECT ANSWER Centers for Medicare and Medicaid According to ANCC (2011), the Magnet Recognition Program recognizes health care organizations that provide nursing excellence and provide a means for disseminating successful nursing practices and strategies. How is information technology tied into this process? - CORRECT ANSWER Informatics and information systems support the process by providing aggregate data related to quality improvement. A hospital client sees the nurse documenting information into the computer. She asks the nurse why the computer is better than the ""old patient chart like hospitals have always used." Which od the following points would be accurate to say about an electronic medical record? Select all that apply. - CORRECT ANSWER -It is more secure than a paper record. -More than one person can access the record at any given time. -The record is available when and where needed. Electronic medical record (EMR) resuts reporting and data repository components include unstructured data. Which of the following are examples of unstructured data? Select all the apply. - CORRECT ANSWER -History and physical -Consultation findings -A social services text report Which of the following answers are basic components of the EMR system? Select all that apply. - CORRECT ANSWER a. Clinical messaging and e-mail b. Results reporting c. Decision support d. Clinical documentation e. Order entry Which of the following are characteristics of stand-alone PHRs? Select all that apply. - CORRECT ANSWER -Some fully standalone applications are available commercially. -The PHR is not tied to any particular health care system. -Standalone PHRs such as those on thumb drive devices have been found to have significant security risks. While most hospitals have some level of automation, few have attended a fully electronic environemt. Health care information and Management System Society (HIMSS) analytics created an EMR adoption model that identifies eight levels of EMR capadabilities. Your hospital has been designed as a Stage 3 facility. Which of the following is accurate about an organization at Stage 3 level? - CORRECT ANSWER Basic clinical documentation and retrieval. Personal health record (PHR) security issues relate to HIPAA and physical security of data. HIPAA only covers PHRs provided by covered entitles such as health plans, health care clearinghouses, and providers. No government coverage exists for other sites unless it is at the state level. To avoid these types of breaches, the American Health Information Community's consumer empowerment working group made a recommendations. Which od the following was recommended for PHR's in order to avoid breaches? - CORRECT ANSWER A PHR certification process Which of the following statements about meaningful issue is correct? - CORRECT ANSWER Meaningful use will provide invaluable information that will improve patient outcomes and population health changing many current practices as we transform out healthcare delivery What is a private, secure application through which an individual may access, manage, and share his or her health information? - CORRECT ANSWER Personal health record PHRs and their functions are becoming more important in health care delivery systems. There are a multitude od benefits associated with PHR. Which of the following is not a potential benefit associated with the PHR and laboratory tests? - CORRECT ANSWER May confuse and worry patients Define Nursing informatics - CORRECT ANSWER A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. What are the 3 sciences involved in nursing informatics? - CORRECT ANSWER Nursing science, computer science, and information science. Describe information theory: - CORRECT ANSWER Processing data to produce information, and, in combination with knowledge and wisdom, using information to provide care. An example is putting the number 39 with celsius that combine to make temperature which is information and synthesized into knowledge= hypothermia, wisdom combines knowledge, values, and experience to make care decisions. Describe another theory involved in nursing informatics: - CORRECT ANSWER Systems theory: interaction with a system will create something bigger and better than just the sum of the parts. What is the difference between an EMR and EHR? - CORRECT ANSWER EMR is an electronic medical record. It has one provider, one entity, once hospital. -EHR: electronic health record is multiple organizations record. It is cumulative. Many EMR's and PHR's come together to make an EHR. What is a PHR? - CORRECT ANSWER Personal health record: these can be on paper or on a website or even a usb drive. The patient controls their own health records with this and can add information. What are 3 benefits of a PHR? - CORRECT ANSWER Can see results faster, can be a preventitive health complication tool, gets patients involved in their own healthcare, gives patients a piece of mind in knowing they can access. What are 3 limitations of a PHR? - CORRECT ANSWER Privacy issues, knowledge about how to do it or what to put, the time it takes to keep it up to date. What is a smart card? - CORRECT ANSWER A secure and portable way to carry PHR. Improves security, privacy, and can reduce health care fraud. They are compliant with government initiatives and are a secure access to emergency medical records. Name 3 core objectives of Stage 1 "meaningful use" requirements of the American Reinvestment and Recovery Act (ARRA)? - CORRECT ANSWER Stage 1: -Maintain an allergy list -Record smoking status for patients 13 yeards or older -Record vital signs Name 3 core objectives of stage 2 of the "meaningful use" requirements of the American Reinvestment and Recovery Act (ARRA)? - CORRECT ANSWER Stage 2: -Include clinical lab test results for HER -Preform medication reconciliation -Submit electronic data to immunization registries Describe how a clinical information system (EMR or EHR) contributes to patient safety. - CORRECT ANSWER Improves legibility, supports safe medication practice (drug interaction/allergy), and improves nursing workflow; eliminated redundant documentation. Give an example of data about a specific quality indicator and describe how that data could b obtained from a clinical information system: - CORRECT ANSWER Falls. On the clinical flowsheet in horizon there is a fall risk tab where risk of the patient is charted and a formula calculated the patients fall risk (high, moderate, or low fall risk) According to nursing researchers Staggers, Gassert, and Curran, what informatics competencies should be demonstrated by Beginning nurses: - CORRECT ANSWER Has fundamental information management and computer technology skills, and uses existing information systems and available information to manage practice. "" According to nursing researchers, what informatics competencies should be demonstrated by experienced nurses: - CORRECT ANSWER Has proficiency in a domain of interest (ex: public health, education, administration). Highly skilled in using information management and computer technology skills to support their major area of practice. Sees relationships among data elements and makes judgements based on trends and patterns within this data. And finally, uses current information systems but collaborated with the informatics nurse specialist to suggest improvement to systems. "" According to nursing researchers, what informatics competencies should be demonstrated by nursing informatics specialists: - CORRECT ANSWER An RN with advanced preparation possessing additional knowledge and skills to information management and computer technology. -Focuses on information needs for the practice of nursing, which includes education, administration, research, and clinical practice. -Practice is built on the integration and application of information science, computer science, and nursing science. -Uses the tools of critical thinking, process skills, data management skills (including identifying, acquiring, preserving, retrieving, aggregating, analyzing, and transmitting data), systems development cycle, and computer skills. "" According to nursing researchers, what informatics competencies should be demonstrated by informatics innovators: - CORRECT ANSWER -Educationally prepared to conduct informatics research and generate informatics theories. -Has a vision of what is possible and a keen sense of timing to make things happen. -Leads the advancement of informatics practice and research. -Functions with an ongoing, healthy skepticism of existing data management practices and is creative in developing solutions. -Possesses a sophisticated level of understanding and skills in information management and computer technology. -Understands the interdependence of systems, disciplines, and outcomes, and can finesse situation and maximize outcomes. Define the term computer fluency: - CORRECT ANSWER Understanding how to use computers and the related computer concepts . This is not to be confused with computer literacy which is a temporary state. What does the acronym QSEN mean? - CORRECT ANSWER Quality and Safety Education for Nurses Name 6 categories of QSEN: - CORRECT ANSWER 1.) patient centered care 2) teamwork and collaboration 3.) evidence based practice 4.) quality improvement 5.) safety 6.)informatics Name 3 nursing literature bibliographic databases: - CORRECT ANSWER 1.) CINAHL 2.) MedLINE 3.)Allied Health Source How do the Boolean operators affect a literature search: - CORRECT ANSWER Increase and/or limit the amount of information retrieved. Using will broaden and or narrow the search. Define the term "research practice pay gap": - CORRECT ANSWER Emerges when there are differences between clinical practice and the research on effectice clinical practice. Name two factors that cause a research practice gap: - CORRECT ANSWER Lack of time, lack of sufficient staff, and access to knowledge resources Define the term "Seminal work": - CORRECT ANSWER Work frequently cited by others or influences the opinion of others Provide a brief definition of a "Just Culture": - CORRECT ANSWER Reporting of error and near misses is supported without fear of retribution. It is nonpunitive. Fair environment, manages performance. Discuss examples of barriers to a Just Culture; how can these barriers be reduced? - CORRECT ANSWER Barriers are employees who frequently make errors, employees intentionally cut corners knowing that there wouldn't be a punishment and also weak leaders. -How these barriers can be reduced is by educating employees and strong leaders. How can informatics be used to monitor errors and support a Just Culture: - CORRECT ANSWER Computers could alert with abnormal, second set of eyes, look up what happened in previous encounters. What is BCMA and how does it contribute to patient safety? - CORRECT ANSWER Bar Code Medication Administration is a system where patients have bar coded wrist bands. These bar codes must be scanned before administering medication. It is supposed to reduce errors when distributing meds. Tells what medication, dose, route, and time. What are some limitations of BCMA? - CORRECT ANSWER Over reliance with technology, funds (its expensive), and emergency situations when time is crucial. If you were a nursing manager, what report data could help you monitor the use of BCMA technology on your nursing unit? - CORRECT ANSWER Error rate and reasons for them, how many times a med was given, how long does it take to administer the meds and how many were given late, day/night errors/ weekend/weekday errors. Describe telenursing and describe how it occurs: - CORRECT ANSWER use of telecommunication and information technology in the provision of nursing services, when there is a larger physical distance between patient and nurse or between any number of nursed. Describe at least two examples of patient assessments that may be accomplished using telenursing: - CORRECT ANSWER Video chat: assess some symptoms, also the transmission of information such as in CPAP. What is the Leapfrog Group and how can a healthcare organization meet the CPOE (computerized physicial order entry) criteria to be recognized by this group? - CORRECT ANSWER It is a large purchaser organization with focus on patient safety and value-promotes transparency through data collection and public reporting from hospitals (other classes). -Tool that allows hospitals to access their medication-safety related decision support -Uses questionaires to assess the standards. How can CPOE contribute to patient safety: - CORRECT ANSWER Eliminates problems with handwriting, prevents patients form getting higher dose than indicated, prevents delays in medication getting to patient. What are potential barriers to CPOE: - CORRECT ANSWER High cost, alert too much, not personable. Define bioinformatics: - CORRECT ANSWER Biological data that uses technology. How did the Human Genome Project utilize bioinformatics? - CORRECT ANSWER Genomic information (DNA & RNA) and linked it to disease via various technologies. Describe an example of data about a specific disease or conditions that could be contained in a bioinformatics database: - CORRECT ANSWER Lupus. This is an autoimmune disorder that can be linked to genes and can be tested for using technology. Name two examples of nursing or medical decision support: - CORRECT ANSWER Potential drug interactions, practicing safety and quality focus such as allergy, fall risk, meds. What does the term "Alert fatigue" mean and how can it impact decision support systems? - CORRECT ANSWER Nurses becoming desensitized to alerts such as bed alarms or pop ups that they begin to ignore. This could result in error rates going up from missing important message when they are just clicking through. What are some benefits and limitations of clinical decision support systems? - CORRECT ANSWER Benefits: unbiased evidence based second opinion, work load, checks and balance. -Limitations: not everyone has access to the same programs, and also standardized practice. Name 4 ways a nurse can follow HIPPA guidelines for securing patient data: - CORRECT ANSWER 1.) Frequently changing your password 2.)Not sharing your password w anyone 3.) Timely logging off 4.) Not sharing information about the patient in public areas where individual is not involved in that patient's care can hear. What are 4 basic guidelines for quality documentation and reporting? - CORRECT ANSWER 1.) Factual: descriptie information. Avoid vague terms (appears, seems, apparently) and also avoid opinions. 2.) Accurate and complete: use of exact measurements, use of accepted abbreviations, concise, clear, and easy to understand, spelling. 3.) Current: timely entries, record near bedside (point of care), electronic documentation, military time. 4.) Organized: logical order: assessment, interventions, client response. Name 5 types of patient data typically found in a hospital's clinical information system? - CORRECT ANSWER 1.) Admission Nursing History Form 2.) Flow sheet and graphic record 3.) Client Care Summary 4.) Standardized Care Plans 5.) Discharge Summary Form Define the terms "cyberchondriac" and "online diagnoser". Discuss the differences between them: - CORRECT ANSWER -Cyberchondriac: a term that describes people who become distressed and frightened after repeated and excessive web searches for health info, it is an anxiety disorder and does not typify most consumer searches for health information. -Online Diagnoser: an individual who searched for online health info, it affects the individuals understanding of any health problem they had and improves their health management. Define the terms "health literacy" and "health numeracy". Name an example of each type of skill: - CORRECT ANSWER -Health literacy: the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Example: the ability to understand instructions on a medication bottle. -Health numeracy: the ability of a consumer to interpret and act on all numerical information such as graphical and probabilistic information needed to make effective health decision. Example: laboratory values and medication schedules.