Q&A Hero

Q: ________________________ PHRs are extensions of physicians' offices. Standard Text:

Q: The Omaha System has a multitude of functions. The system can store data describing problems, symptoms, modifiers, interventions, and outcomes. One of the benefits of the stored data is which of the following? 1. Decreasing services to elderly 2. Allowing patient input of data 3. Researching quality and effectiveness 4. Decreasing time spent with data collection

Q: Which of the following functionalities can be found with the personal health record (PHR)? Standard Text: Select all that apply. 1. Entering medical history 2. Entering allergies 3. Entering present medication alerts 4. Entering past social history 5. Entering family history

Q: The use of SNOMED CT within electronic health records has multiple benefits. Which of the following are considered benefits of SNOMED CT? Standard Text: Select all that apply. 1. Provides interoperable data collection that can be analyzed and used for evidence-based practice models 2. Provides interoperable data collection that can be analyzed and used for decision support rules 3. Provides interoperable data collection that can be analyzed and used in reporting quality measures 4. Provides interoperable data collection that can be analyzed and used for medication renewals 5. Provides interoperable data collection that can be analyzed and used for administrative billing

Q: Some functionalities require integration between the PHR and a scheduling application. Which of the following is a benefit of this communication? 1. Integration between a scheduling application and the PHR allows the patient to locate a physician's practice in a new region. 2. Integration between a scheduling application and the PHR allows the patient to have instant access with a health care provider's staff. 3. Integration between a scheduling application and the PHR allows the patient to schedule an appointment without making a telephone call. 4. Integration between a scheduling application and the PHR allows the patient to send notes and updates to the health care provider's office.

Q: Standard terminologies have been scientifically investigated for their effectiveness and impact on patient care. The use of standard terminologies can, therefore, facilitate the use of which of the following? 1. Multiple support languages 2. Consumer informatics 3. Computer literacy 4. Evidence-based practice and decision support rules

Q: In its simplest form, the PHR is a stand alone system where the _______________enters data. Standard Text:

Q: The impact of standardized terminology throughout the U.S. health care system has grown exponentially. Medicare and Medicaid have begun to offer financial incentives to health care providers to promote adoption and meaningful use of interoperable health information systems and a qualified health record. Which of the following statements best describes meaningful use? 1. The goal of meaningful use is to input data in a manner that creates evidence-based practice models. 2. The goal of meaningful use is to exchange clinical structured data in a manner that is accurate and complete to improve patient care in a cost-efficient way. 3. The goal of meaningful use is to provide a warehouse of data that supports medication renewal and patient teaching plans. 4. The goal of meaningful use is to offer the clinician patient care tools for improved outcomes.

Q: PHRs and their functions are becoming more important in health care delivery systems. There are a multitude of benefits associated with the PHR. Which of the following is not a potential benefit associated with the PHR and laboratory tests? 1. May confuse and worry patients 2. Avoids letters and phone calls 3. Reduces patient waiting time 4. All data are confidential

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: Which of the following is a nursing classification designed to document the six steps of the nursing process across the care continuum? 1. International Classification of Nursing Practice (ICNP) 2. NANDA International Nursing Diagnoses 3. NANDA-I Taxonomy II 4. Clinical Care Classification (CCC) System

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: ______________________________ is a globally recognized controlled health care vocabulary that provides a common language for electronic health applications. Standard Text:

Q: The ANA has recognized the Omaha System and integrated the terminology into SNOMED CT. Which of the following best represents the value of the Omaha System? 1. The Omaha System is a problem classification scheme. 2. The Omaha System offers outcome labels. 3. The Omaha System provides nursing diagnoses. 4. The Omaha System provides diagnoses and intervention.

Q: During the orientation to the renal oncology unit, the head nurse demonstrated the usefulness of the Clinical Care Classification (CCC) System. Throughout the demonstration, the head nurse discussed the value of the system to patient care. Which of the following statements best reflects the usefulness of CCC? 1. The Clinical Care Classification (CCC) System facilitates the collection and dissemination of lab values. 2. The Clinical Care Classification (CCC) System offers improved outcomes. 3. The Clinical Care Classification (CCC) System facilitates patient care documentation at the bedside. 4. The Clinical Care Classification (CCC) System discloses standardized nursing terminologies.

Q: Which of the following can be used to document the elements of the nursing process within the care plan? 1. The Omaha System 2. The PeriOperative Nursing Data Set 3. Personal health record 4. NANDA-I

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: _______________________________________ is standardized classification of interventions that describes the activities that nurses perform. Standard Text:

Q: The relationship between meaningful use and the adoption of the EHR in hospitals, physician offices, and other settings is best described as which of the following? 1. The meaningful use requirement must be considered before beginning the development process. 2. The meaningful use requirement is achieved with the adoption and use of the EHR system as part of the daily routine. 3. The meaningful use requirement is unique to every health care provider. 4. The meaningful use requirement and use of EHR systems are unrelated.

Q: Which of the following answers depicts the use of the ANA recognized nursing classifications to codify data? 1. The ANA recognized nursing classifications codify data used during the nursing process such as assessments, nurse sensitive problems, interventions, and outcomes. 2. The ANA recognized nursing classifications codify data is used to support input devices. 3. The ANA recognized nursing classifications align nursing outcomes. 4. The ANA recognized nursing classifications codify data for retrieval of billing invoices.

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: Mr. Gonzalez is scheduled to undergo a hip replacement after he slipped on an icy step. During the preoperative phase, the nurse begins to enter the assessment findings into the database. Which of the following standardized terminologies will the nurse most likely use? 1. The Omaha System 2. The PeriOperative Nursing Data Set (PNDS) 3. North American Nursing Diagnosis International (NANDA-I) 4. International Classification of Nursing Practice (ICNP)

Q: The goals of implementing the EHR in all health care systems are fraught with a number of roadblocks. The largest barrier facing most institutions is which of the following? 1. The lack of fully trained professional staff 2. A technology committee that cannot agree on the institution's needs 3. Indecision regarding the choice of vendors 4. Cost

Q: 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

Q: Which of the following are considered impediments to a fully functional electronic health record (EHR) system? Standard Text: Select all that apply. 1. Development of an electronic infrastructure 2. Cost 3. Common vocabulary 4. Caregiver compliance 5. Privacy

Q: A classification system is used to categorize the details of the clinical encounter. Which of the following does a classification system not do? 1. Group data to determine costs and outcomes of treatment 2. Captures the level of detail necessary to document specific items at the point of care 3. Provides data to consumers on costs and outcomes of treatment options 4. Used in the collection and reporting of health statistics

Q: Which of the following terms is defined as structured and controlled languages that have been developed according to terminology development guidelines? 1. Standardized terminologies 2. Health care standards 3. Health care terminology 4. Health information standards

Q: The use of which of the following is a means of ensuring the data collection is accurate and valid? 1. Standardized terminology 2. Tablets 3. Bar coding 4. Handheld devices

Q: The use of standardized nursing terminology will result in better ______________________ among the interdisciplinary team. Standard Text:

Q: The American Nurses Association established criteria for recognizing standardized terminologies. The terminologies must meet established criteria to be approved. Which of the following are instrumental in the approval process? Standard Text: Select all that apply. 1. Outcome identification 2. Diagnosis 3. Problem solving 4. Decision making 5. Nursing process data elements

Q: Personal health record (PHR) security issues relate to HIPAA and physical security of data. HIPAA only covers PHRs provided by covered entities such as health plans, health care clearinghouses, and providers. No governmental 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 recommendation. Which of the following was recommended for PHRs in order to avoid breaches? 1. Deletion of sensitive data 2. Educating the general consumer about PHRs 3. Restricting the number of authorized users 4. A PHR certification process

Q: The EHR offers benefits to nurses, physicians, and other health care providers, the health care enterprise, and most importantly, the consumer. Much must be done before the benefits associated with the EHR can be realized. Which of the following is one action that has been proposed by experts? 1. Health care professionals should institute major changes in the way they work. 2. Consumers need education to choose providers based upon appropriate financial and insurance considerations. 3. Individual consumers should have lesser responsibility for data. 4. Government intervention should promote information exchange among software vendors and health care systems.

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: Electronic medical record (EMR) result reporting and data repository components include unstructured data. Which of the following are examples of unstructured data? Standard Text: Select all that apply. 1. Automated laboratory results 2. History and physical 3. Consultation findings 4. Magnetic resonance imaging 5. A social services text report

Q: Information in the electronic health record (EHR) may be owned by the patient or stakeholder. Which of the following about the EHR is different than the electronic medical record (EMR)? 1. It does not provide interactive client access. 2. Clients may append information if desired. 3. Dental records components are not included. 4. The EHR records and manages only episodic information.

Q: The mere implementation of an electronic medical record (EMR) does not guarantee that benefits will be achieved. Which of the following can affect data integrity? 1. System failure 2. Data analysis 3. Data downloading 4. Data mining

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: Which of the following statements about meaningful use is correct? 1. Meaningful use will provide invaluable information that will define the numbers of staff members needed at the bedside. 2. Meaningful use will provide invaluable information that will improve patient outcomes and population health changing many current practices as we transform our health care delivery system. 3. Meaningful use is an ongoing process and not an issue associated with the EHR. 4. Meaningful use is an issue that must be addressed before implementing any upgrade.

Q: Which of the following is a major component of the computer-based patient record (CPR)? 1. Results reporting including unstructured data reports 2. Legal record created in hospitals and ambulatory environments 3. Support for links to local or remote information resources 4. Integration of all pertinent patient information into one record

Q: The computer-based patient record (CPR) is a comprehensive lifetime record that includes all information from all specialties. Most of the data included in the CPR is which of the following? 1. Structured data 2. Unstructured data 3. Fragmented data 4. Complete data

Q: The Bush administration called for the adoption of the electronic health record (EHR) by 2014 as a means to help transform U.S. health care. Who owns the individual client record when an EHR is used? 1. The client 2. Ownership is unclear 3. The institution at which the record is created 4. The health care providers who enter the data

Q: Which of the following are major impediments to the development of an electronic health record (EHR)? Standard Text: Select all that apply. 1. Development of an electronic infrastructure 2. Confidentiality 3. Cost 4. Lack of a common vocabulary 5. Information system vendors

Q: Which of the following statements is true about the benefits of the electronic health record (EHR)? 1. It improves the quality of health care. 2. Health care executives have developed strong organizational structures around the EHR. 3. The EHR fosters continuity of health care. 4. Little scientific evidence now exists on what benefits are actually delivered.

Q: Healthcare Information and Management Systems Society (HIMSS) has defined and described the term electronic Personal Health Record (ePHR). Which of the following are included in the HIMSS definition and description? Standard Text: Select all that apply. 1. Universally accessible 2. Owned and managed by the individual (or legal proxy) 3. Usually considered a legal record 4. Common data set of electronic health information 5. Lifelong tool for managing relevant health information

Q: Consumers are the primary source of information about their health history and medications. The patient-carried record (PCR) addresses this. Which of the following are potential problems associated with the PCR? Standard Text: Select all that apply. 1. Loss of the record 2. Legibility 3. Portability 4. Privacy 5. Liability

Q: Unlike other health records the _____________________is patient-centered, presenting a more-balanced view of an individual's health history. Standard Text:

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: 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: Which of the following are found with the electronic health record (EHR) but are not found with the computer-based patient record (CPR)? Standard Text: Select all that apply. 1. Evidence-based decision support 2. Assists with the work of planning and delivering evidence-based care 3. Quality management 4. Public health disease surveillance and reporting 5. Comprehensive lifetime record that includes all information from all specialties

Q: One step in the integration process is the development of a uniform definition of terms, or language. The American Nurses Association sponsors the Congress of Nursing Practice Steering Committee on Databases. Which of the following is a primary goal of this steering committee? 1. Categorize interventions that nurses carry out. 2. Measure client outcome position. 3. Develop a mapping system to link various classification schemes. 4. Identify client care problems that nurses treat independently.

Q: 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 of the following points would be accurate to say about an electronic medical record? Standard Text: Select all that apply. 1. It captures the information needed for billing purposes. 2. It is more secure than a paper record. 3. More than one person can access the record at any given time. 4. The record is available when and where needed. 5. Data are in real-time, as things happen.

Q: Web-based tools can provide benefits of an alternative method for obtaining patient information from diverse information systems. Which of the following is accurate regarding recent advances toward interoperability? 1. The framework has been built and is in place. 2. National priorities will be set within the next five years. 3. Data exchange standards need to be developed. 4. Interoperability of electronic health data will be costly.

Q: Which of the following topics must be addressed when giving a presentation to physicians on the benefits of the electronic medical record (EMR)? Standard Text: Select all that apply. 1. Easier access to previous documented encounters 2. Facilitation of clinical pathways 3. Chart access speed 4. Trends and graphics are not available on demand 5. Reduced liabilities through accurate documentation

Q: Interface engines work in the background and are not seen by the user. This technology allows applications to interact with hardware and other applications. Which of the following are considered benefits associated with the use of interface engines? Standard Text: Select all that apply. 1. Improves timeliness and availability of critical administrative and clinical data 2. Improves data quality because of data mapping and consistent use of terms 3. Allows clients to select the best system for their needs 4. Preserves institutional investment in existing systems 5. Preserves institutional investment in existing systems

Q: While most hospitals have some level of automation, few have attained a fully electronic environment. Health care Information and Management Systems Society (HIMSS) analytics created an EMR adoption model that identifies eight levels of EMR capabilities. Your hospital has been designated as a Stage 3 facility. Which of the following is accurate about an organization at Stage 3 level? 1. Computerized provider order entry (CPOE) and better EBP clinical decision support is available. 2. Some clinical automation exists. 3. Basic clinical documentation is required. 4. Major ancillary clinical systems are all installed (laboratory, pharmacy, and radiology systems).

Q: Integration is a massive project within institutions and enterprises. It generally requires more time and effort than originally projected. Which of the following are factors that may slow down the integration process? Standard Text: Select all that apply. 1. Unrealistic institutional timetable 2. Lack of agreement among merged institution 3. Insufficient documentation 4. Changing user specifications 5. Lack of vendor support

Q: The U.S. Department of Health and Human Services indicated that the ________________ is a digital collection of patient's medical history. Standard Text:

Q: Nursing can reap significant benefits from integration. Which of the following integration statements is accurate for nursing? 1. Trends in client care data and cost analysis can be used to justify nursing staffing levels. 2. Nursing should be sure that data will be collected in several systems for sharing. 3. The use of a data dictionary can interfere with system integration processes. 4. Nursing involvement is unnecessary so long as I.S. staff members are given requirements.

Q: The clinical data repository provides data definition consistency through which of the following? 1. Mapping 2. Interface engine 3. Point-to-point interface 4. Clinical data warehouse

Q: _______________________ uses XML (Extensible Markup Language) for storage and movement of clinical documents between systems. Standard Text:

Q: ______________________________ interoperability is the ability to exchange the structure of the data, but not necessarily the meaning of the data. It is also referred to as functional interoperability. Web pages built with HTML illustrate this type of interoperability. Standard Text:

Q: Which of the following supports the development of an EHR by classifying and categorizing nursing data? 1. North American Nursing Diagnosis Association (NANDA) 2. HL7 3. Service oriented architecture (SOA) 4. SNOMED

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: 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: 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: 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: What uses archetypes (clinical models of content and process) as a means of exchanging clinical documents between systems? 1. Service oriented architecture 2. HL7 3. Open EHR 4. Semantic interoperability

Q: Which of the following is a classification system for surgical, diagnostic, and therapeutic procedures and is used for hospital billing and payer reimbursement? 1. NOC 2. CPT-4 3. NIC 4. NANDA

Q: Nurses must be involved in identifying and defining data elements that an interface may be able to supply. One way to ensure participation is to recruit staff nurses to do which of the following? 1. Provide input during the interface design. 2. Be a member of the technology committee 3. Participate in the creation of a RFP. 4. Define language needed for interoperability.

Q: The role of the nurse in the system integration efforts should include which of the following? Standard Text: Select all that apply. 1. Ensuring that data will be collected in only one system and shared as needed among others 2. Involvement in the formation and maintenance of the electronic health record 3. Promoting the development and maintenance of archetypes 4. Determining measures to assure the quality of data 5. Identifying and defining data elements

Q: ____________________ and Internet technology were seen as a means to provide access to data from disparate information systems. Standard Text:

Q: The security of any information system is part of the strategic planning process. Information system security is planned for with the intention of achieving which of the following goals? Standard Text: Select all that apply. 1. Patient confidentiality protection 2. Information integrity protection 3. Timely availability protection 4. Cybercrime prevention 5. HIT compliance

Q: Which of the following is true about effective security? 1. Assessment of security resources enables organizational personnel to devise methods to protect information systems data. 2. Assessment of security resources provides super users with in depth access knowledge. 3. Assessment of security resources enables organizational personnel to alter the flow of information. 4. Assessment of security resources enables organizational personnel to define terms in the data dictionary.

Q: ______________________________ is the process of determining whether someone is who he or she professes to be. This usually involves a username and a password, but can include other methods of proving identity, such as a smart card, retina scan, voice recognition, or fingerprints. Standard Text:

Q: Which of the following best depicts the impact that Internet technology has on the security of health related information? 1. Health information on the Internet requires the same types of safeguards provided for information found in private offices and information systems. 2. Health information on the Internet does not require the same types of safeguards provided for information found in private offices and information systems. 3. Health information on the Internet requires more types of safeguards than what are provided for information found in private offices and information systems. 4. Health information on the Internet requires fewer safeguards than what are provided for information found in private offices and information systems.

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: What is the primary purpose of system integration in a health care facility? 1. Provide reliable flow of information between facility and physician offices 2. Offer seamless data exchange among disparate information systems 3. Prevent system data errors via large scale electronic exchanges 4. Customize information systems within a department

Q: The timely flow of information is critical to institutional survival. Which of the following statements about interfaces is accurate? 1. Interfaces use an open systems technology provided by the vendor. 2. Interfaces require installation of a Health Level Seven (HL7) device. 3. Interface connections between different information systems are invisible to the user. 4. Interfaces physically join two or more disparate information systems.

Q: Health Level Seven (HL7) standards are not the only standards that are evolving to fit the changing health care model. What other organizations are instrumental in supporting the development of standards and helping to define data exchange? Standard Text: Select all that apply. 1. Department of Defense 2. Centers for Medicare and Medicare Services 3. National Science Foundation 4. Institute of Medicine 5. American Medical Informatics Association

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