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Question
Clinical terminologies consist of concepts that support which of the following facets of health care?
Standard Text: Select all that apply.
1. Diagnostic studies
2. History and physical examinations
3. Visit notes
4. Ancillary department information
5. Outcomes measures
Answer
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Related questions
Q:
An emerging technology related to electronic health record (EHR) progress is the use of the personal health record (PHR). PHRs store client information that will eventually contribute to the development of a comprehensive, longitudinal record. Which of the following are found in a PHR but not found in the EHR?
Standard Text: Select all that apply.
1. Periodic risk assessment survey results
2. Herbal supplements
3. Legal documentation created in a hospital
4. Decision support
5. Health status parameters such as exercise
Q:
The computer-based patient record (CPR) is a comprehensive lifetime record that includes all information from all specialties. The Institute of Medicine (IOM) identified major components of the CPR that are considered to be the "gold standard" attributes. Which of the following are CPR components?
Standard Text: Select all that apply.
1. Lack of confidentiality
2. Direct entry for physicians will be available
3. Tools cannot measure cost
4. Provides sporadic access to data
5. Provides a patient problem list
Q:
For many years the EMR applied to a single encounter with no ability, or very limited ability, to carry information from one visit to another within a care delivery system. That situation has changed; it is now possible to bring information forward from prior visits within the organization or delivery system. Which of the following answers are basic components of the EMR system?
Standard Text: Select all that apply.
1. Clinical messaging and e-mail
2. Results reporting
3. Decision support
4. Clinical documentation
5. Order entry
Q:
What is a computer program that tells two different systems how to exchange data?
1. An interface
2. Request for proposal
3. Syntactic operability
4. HL7
Q:
Using what kind of strategy will permit data exchange within each hospital and across health care networks or enterprises?
1. Integration
2. Syntactic interoperability
3. Semantic interoperability
4. Using a clinical data repository
Q:
The lack of which of the following has long been a barrier to effective data reporting and analysis?
1. Knowledge
2. Interoperability
3. Resources
4. Information technology
Q:
The use of HL7 standards in individual applications can improve the integration of applications with other applications or systems through the use of which of the following?
1. Digital imaging and communications in medicine (DICOM)
2. Interface engine
3. Radiology information system (RIS)
4. Current procedural terminology (CPT) codes
Q:
_______________________ uses XML (Extensible Markup Language) for storage and movement of clinical documents between systems.
Standard Text:
Q:
A female client goes to the clinic's office complaining of a cough and fever. She gives her name and date of birth at the admitting registration desk. The registration clerk verifies her current address and asks if she is still covered by IVY insurance. Client responds yes, is given a chart with the number 3948JAV04830 on it, and is directed to the physician's exam room. The physician orders a chest x-ray. The client is sent to the radiology department and checks in with the registration desk. The registration clerk verifies her current address and asks if she is still covered by IVY insurance. The client responds yes and is given an order sheet with the number 3948JAV04830 on it. The admitting office for the clinic and the radiology office use different information systems. The process depicted in this scenario illustrates the use of which of the following?
1. Uniform language
2. Master patient index
3. Data dictionary
4. Clinical data repository
Q:
What are the benefits of data integration?
Standard Text: Select all that apply.
1. Potential for improved remote access of clinical data from various systems
2. Trend analysis of financial and clinical data
3. Encouraging the use of systems customized to meet department specifications
4. Development of a computer-based patient record
5. Facilitation of data collection for accreditation purposes
Q:
Terminologies can be incorporated within the electronic health record (EHR) thereby improving practice. Which of the following are considered uses for this technology in health care?
Standard Text: Select all that apply.
1. Classification
2. Reference
3. Point of care
4. Coding
5. Denial of claims
Q:
Which of the following terminologies have been approved by the American Nurses Association?
Standard Text: Select all that apply.
1. Nursing Management Minimum Data Set (NMMDS)
2. Nursing Minimum Data Set (NMDS)
3. Alternative Billing Codes (ABC Codes)
4. Clinical Care Classification (CCC)
5. North American Nursing Diagnosis International (NANDA-I)
Q:
_________________________ would permit the uniform capture of data required to build a longitudinal record comprised of integrated information systems from multiple vendors.
Standard Text:
Q:
Which of the following best describes the electronic medical record (EMR)?
1. Legal record created in hospitals
2. Legal record created by vendors
3. An electronic stand alone database
4. Method to identify outcomes
Q:
The electronic health record (EHR) has the potential to integrate all pertinent patient information into one record. It also has potential to improve the quality of health information, patient safety, and productivity, contain costs, support research, decrease wait time for treatment and contribute to the body of health care knowledge. Which of the following are reasons why traditional paper records on clients no longer meet the needs of today's health care industry?
Standard Text: Select all that apply.
1. Paper records are episode-oriented with a separate record for each client visit.
2. Key information may be lost from one episode to the next, jeopardizing patient safety.
3. Only one person can access a paper record at any given time.
4. Different versions of the same information may be stored in several places.
5. Paper records cannot incorporate diagnostic studies that include images and sound.
Q:
The master patient index (MPI) is a database that lists all identifiers assigned to one client in all the information systems used within an enterprise. It assigns a global identification number for each client and allows clients to be identified by demographic information provided at the point of care. When the MPI cannot match a client's record based on demographic data, what is provided to the user?
1. The data dictionary resources
2. Non-citizen information so that the user may find a different identifier
3. All possible matches so that the user may view and select
4. The Social Security number
Q:
The Health Insurance Portability and Accountability Act (HIPAA) requires organizations to determine threats and appropriate protective measures for information, not only in electronic formats, but in all formats. Which of the following measures cannot be incorporated by organizations to secure all data?
1. Creation of authentication policies
2. Specific software
3. Spyware
4. Firewall
Q:
Which of the following measures are recommended for enhancing information security?
Standard Text: Select all that apply.
1. File deletion software is used to overwrite hard disk files, using meaningless information.
2. Storage media that has been erased is disposed of in the dumpster.
3. Individuals routinely witness and record the destruction of records.
4. Papers such as prescriptions, laboratory specimen labels, and identification bracelets are disposed of in the dumpster.
5. Each page of output is assigned a serial number and the numbers are recorded when documents are destroyed.
Q:
Passwords are a common means to authenticate access to automated records. Which of the following are recommendations for password selection and use?
Standard Text: Select all that apply.
1. Using software to test and eliminate easily compromised passwords
2. Using the browser "password save" feature
3. Deleting and replacing all system user passwords when an employee is terminated
4. Storing passwords in a file on the computer
5. Using the same password for access to all sites or systems
Q:
A(n) ____________________ is one of the greatest threats that may come from inside sources, namely employees, contractors, consultants, outsourced services, and vendors who view information inappropriately, disrupt information availability, or corrupt data integrity.
Standard Text:
Q:
A certified nursing assistant (CNA) at a local nursing home logs on to the facility's clinical information system. The CNA can only see information about the clients that were assigned by the registered nurse for that day. The CNA cannot see financial data regarding any of the assigned clients. This situation is an example of which of the following?
1. Password protection
2. Computer forensics
3. Access levels
4. User authentication
Q:
Why do most breaches of confidentiality occur?
1. Malicious behavior
2. System hacking
3. Intent
4. Carelessness
Q:
The ongoing maintenance of the technical issues is the role of which of the following departments?
1. Nursing
2. Information services department
3. Computer programmers
4. Vice president of technology
Q:
Implementation of any system can be facilitated by the committee's understanding of the amount of time that is needed to successfully complete the project. To that end, what is an important staffing concept for administration to consider when appointing members to a technology committee?
1. Committee member must equally divide duties to complete tasks.
2. Committee members should meet more than once a week to complete tasks.
3. All member of the committee need a comprehensive technology background.
4. Relevant committee members can be given alternate work assignments to accommodate the increase in committee work.
Q:
Which of the following critical elements apply to the development of the timeline prior to implementation of the system?
Standard Text: Select all that apply.
1. Necessary tasks
2. Scope of each task
3. The members' roles and responsibilities in accomplishing the tasks
4. Driving forces of the market
5. Development of crib sheets
Q:
When selecting the chair of the technology committee who is charged with leading the committee members and decision making regarding implementation of the new system, the best person suited for this role would be which of the following?
1. The vice president of nursing
2. Informatics nurse specialist
3. Information technology programmer
4. Staff nurses affected by the system implementation
Q:
To change the culture of any work environment, the nurse as a leader can promote innovation and minimize resistance through which of the following?
1. Demanding staff listen to rationale behind the changes
2. Planning a strategy to support people and process changes
3. Asking staff to trust their colleagues
4. Understanding that the change is for their benefit
Q:
Which of the following is not an example of a function?
1. Upgrading
2. Order entry
3. Results reporting
4. Documentation
Q:
Which of the following best defines data dictionaries?
1. Data dictionaries contain lists and definitions of all terms used.
2. Data dictionaries contain actual data.
3. Data dictionaries have nothing to do with data quality.
4. Data dictionaries can be found in the nursing office.
Q:
The implementation committee members analyze the base system as delivered from the vendor before the system is installed in the event that clarification or changes are necessary. Which of the following are analyzed throughout this process?
Standard Text: Select all that apply.
1. Technology
2. Vendor standing
3. Vendor compliance with regulatory requirements
4. Integration with other systems
5. Clinician support