NR599: Comprehensive Final
Ethical Decision Making -Process that requires striking a balance between science and
morality.
-Making informed choices about ethical dilemmas based on a set of standards differentiating
right from wrong.
American Nurses Association- Code of Ethics for Nurses with Interpretive Statements.
provides specific guidance for ethical decision making and provides a valuable
framework that can be used when working with HIT
Bioethical Standards Autonomy, freedom, veracity, privacy, beneficence, and fidelity are
maximally appropriate to the health care setting.
Autonomy The right to choose for himself or herself; respecting the clients opinions,
perspectives, values and beliefs.
Freedom The ability of an individual to act independently, without coercion or constraint in
ones choice and action
veracity Being completely truthful with patients; a patients right to truth.
privacyThe right to be left alone when you want to be, to have control over your own personal
possessions, and not to be observed without your consent
Beneficence Actions performed that contribute to the welfare of others; Action of doing good
or right by and for the patient.
Fidelity Right to what has been promised; keeping to one's promise.
Telehealth Use of electronic information and telecommunications technologies to support
long-distance clinical health care, patient and professional health-related education, public health
and health administration. Technologies include videoconferencing, the internet, store-and-
forward imaging, streaming media, and terrestrial and wireless communications.
Telemedicine Remote clinical health services
mHealth (Mobile Health) -The practice of medicine and public health supported by mobile
devices such as mobile phones, tablets, personal digital assistants and the wireless infrastructure.
-The use of wireless communication to support efficiency in public health and clinical practice.
Mobile Medical Applications (Apps) -Accessories to a regulated medical device or are a
software that transforms a mobile platform into a regulated medical device.
-Facilitates mHealth
Medical Devices Any equipment, instrument, implant, material, or apparatus used for the
diagnosis, treatment, or monitoring of patients.
Rationale APP is NOT Considered Medical Devices Apps that are not intended for use in the
diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of
disease.
FDA Oversight for Medical Devices -Regulatory body that oversees mobile apps that are
medical devices and whose functionality could pose a risk to a patient's safety if the mobile app
were to not function as intended.
, -Also oversee the cybersecurity management of these devices as well as the hospital network
security.
(POC) Point of Care Testing and diagnosis at the patient's side and can be conducted anywhere
the patient is, such as the home, physician office, ambulance, or hospital bedside
Privacy Practice of maintaining the security and confidentiality of patient records.
Confidentiality The act of holding information in confidence, not to be released to
unauthorized individuals.
Cybersecurity -Measures taken to protect a computer or computer system against unauthorized
access or attack.
-FDA is main regulatory agency
Computer-aided Translators Language translation in which a human translator uses computer
hardware to support and facilitate the translation process.
HIPPA (Health Insurance Portability and Accountability Act) Enacted in 1996; federal law
that required the creation of national standards to protect sensitive patient health information
from being disclosed without the patient's consent or knowledge.
ICD-10 Codes -Alphanumeric codes used by doctors, health insurance companies, and public
health agencies across the world to represent diagnoses.
-Shorthand for the patient's diagnosis , which are used to provide the payer information on the
necessity of the visit or procedure performed
CPT Codes (current procedural terminology)official procedural coding rules and guidelines
required when reporting medical services and procedures performed by physician and non-
physician providers
Evaluation and Management Coding process by which physician-patient encounters are
translated into five digit CPT codes to facilitate billing.
Necessity for establishing E/M Codes Place of Service; Type of Service; Patient Status
Components of Risk Based E/M Coding History; Physical; Medical Decision Making
Medical Decision Making (MDM) 1 of 3 components to establishing E/M codes; way of
quantifying the complexity of thinking that is required for the visit.
3 key elements to medical decision making risk, data, and diagnosis
Reimbursement Coding -Claims and documentation filed by providers using medical
diagnosis and procedure codes.
-Assigned contingent upon data input from clinical team members based on a summative review
of the clinical record by trained coders.
Clinical Support Tools -Found in EHR software that when applied effectively, can
enhance patient care quality and outcomes, improve efficiency, and help to ensure regulatory
compliance.
-Process designed to aid directly in clinical decision making, in which characteristics of
individual patients are used to generate patient specific interventions, assessments,
recommendations, or other forms of guidance for clinicians, patients, and others involved in care
delivery.
Alert Fatigue Main challenge to effective implementation of CDS Tools
Primary Goal of CDS Tools leverage data and the scientific evidence to help guide appropriate
decision making.
Workflow -Term used to describe the action or execution of a series of tasks in a prescribed
sequence.
Ethical Decision Making -Process that requires striking a balance between science and
morality.
-Making informed choices about ethical dilemmas based on a set of standards differentiating
right from wrong.
American Nurses Association- Code of Ethics for Nurses with Interpretive Statements.
provides specific guidance for ethical decision making and provides a valuable
framework that can be used when working with HIT
Bioethical Standards Autonomy, freedom, veracity, privacy, beneficence, and fidelity are
maximally appropriate to the health care setting.
Autonomy The right to choose for himself or herself; respecting the clients opinions,
perspectives, values and beliefs.
Freedom The ability of an individual to act independently, without coercion or constraint in
ones choice and action
veracity Being completely truthful with patients; a patients right to truth.
privacyThe right to be left alone when you want to be, to have control over your own personal
possessions, and not to be observed without your consent
Beneficence Actions performed that contribute to the welfare of others; Action of doing good
or right by and for the patient.
Fidelity Right to what has been promised; keeping to one's promise.
Telehealth Use of electronic information and telecommunications technologies to support
long-distance clinical health care, patient and professional health-related education, public health
and health administration. Technologies include videoconferencing, the internet, store-and-
forward imaging, streaming media, and terrestrial and wireless communications.
Telemedicine Remote clinical health services
mHealth (Mobile Health) -The practice of medicine and public health supported by mobile
devices such as mobile phones, tablets, personal digital assistants and the wireless infrastructure.
-The use of wireless communication to support efficiency in public health and clinical practice.
Mobile Medical Applications (Apps) -Accessories to a regulated medical device or are a
software that transforms a mobile platform into a regulated medical device.
-Facilitates mHealth
Medical Devices Any equipment, instrument, implant, material, or apparatus used for the
diagnosis, treatment, or monitoring of patients.
Rationale APP is NOT Considered Medical Devices Apps that are not intended for use in the
diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of
disease.
FDA Oversight for Medical Devices -Regulatory body that oversees mobile apps that are
medical devices and whose functionality could pose a risk to a patient's safety if the mobile app
were to not function as intended.
, -Also oversee the cybersecurity management of these devices as well as the hospital network
security.
(POC) Point of Care Testing and diagnosis at the patient's side and can be conducted anywhere
the patient is, such as the home, physician office, ambulance, or hospital bedside
Privacy Practice of maintaining the security and confidentiality of patient records.
Confidentiality The act of holding information in confidence, not to be released to
unauthorized individuals.
Cybersecurity -Measures taken to protect a computer or computer system against unauthorized
access or attack.
-FDA is main regulatory agency
Computer-aided Translators Language translation in which a human translator uses computer
hardware to support and facilitate the translation process.
HIPPA (Health Insurance Portability and Accountability Act) Enacted in 1996; federal law
that required the creation of national standards to protect sensitive patient health information
from being disclosed without the patient's consent or knowledge.
ICD-10 Codes -Alphanumeric codes used by doctors, health insurance companies, and public
health agencies across the world to represent diagnoses.
-Shorthand for the patient's diagnosis , which are used to provide the payer information on the
necessity of the visit or procedure performed
CPT Codes (current procedural terminology)official procedural coding rules and guidelines
required when reporting medical services and procedures performed by physician and non-
physician providers
Evaluation and Management Coding process by which physician-patient encounters are
translated into five digit CPT codes to facilitate billing.
Necessity for establishing E/M Codes Place of Service; Type of Service; Patient Status
Components of Risk Based E/M Coding History; Physical; Medical Decision Making
Medical Decision Making (MDM) 1 of 3 components to establishing E/M codes; way of
quantifying the complexity of thinking that is required for the visit.
3 key elements to medical decision making risk, data, and diagnosis
Reimbursement Coding -Claims and documentation filed by providers using medical
diagnosis and procedure codes.
-Assigned contingent upon data input from clinical team members based on a summative review
of the clinical record by trained coders.
Clinical Support Tools -Found in EHR software that when applied effectively, can
enhance patient care quality and outcomes, improve efficiency, and help to ensure regulatory
compliance.
-Process designed to aid directly in clinical decision making, in which characteristics of
individual patients are used to generate patient specific interventions, assessments,
recommendations, or other forms of guidance for clinicians, patients, and others involved in care
delivery.
Alert Fatigue Main challenge to effective implementation of CDS Tools
Primary Goal of CDS Tools leverage data and the scientific evidence to help guide appropriate
decision making.
Workflow -Term used to describe the action or execution of a series of tasks in a prescribed
sequence.
