Nursing Informatics - Chapter 15
standardized nursing terminology
A structured vocabulary that provides a common means of communication among nurses
Nursing Minimum Data Set (NMDS)
Represents the first attempt to standardize the collection of essential nursing data
A famous rock star has just been admitted to Unit 12A after an automobile accident. A nurse on Unit 12B who is a fan of the musician uses the electronic health record (EHR) to find out how the patient is doing. Which is true regarding the use of a patient's EHR? a. Only staff caring for the patient should access this record. b. Permission from a supervisor is needed to read this record. c. The patient's record can be discussed with the nurse's co-worker. d. The nurse can call a friend who works at the local newspaper.
a
Which activity by a unit nurse demonstrates information literacy? a. Researching a patient's diagnosis online b. Entering patient data into the electronic health record (EHR) c. Organizing patient data to study trends d. Learning a new electronic health record system
a
Which items are supported by point-of-care use of information technology? (Select all that apply.) a. More accurate documentation b. Direct access to diagnostic results c. Confidentiality d. Direct access to records by patients e. Access to medication profiles
a b c e
Which behaviors are expected of the nurse at the experienced informatics competency level? (Select all that apply.) a. Collect accurate assessment data. b. Conduct informatics research. c. Group assessment data. d. Document data appropriately on the electronic health record (EHR). e. Integrate information science, computer science, and nursing science.
a c d
listserv
a computer program that automatically sends messages to multiple e-mail addresses on a mailing list
blog
a social medium that is usually maintained by an individual and has regular entries of commentary, descriptions of events or other materials such as graphics or videos
nursing informatics
a specialty area that addresses the use of health information systems to support nursing practice
experienced nursing informatic skills
able to see data relationships and make judgments based on trends and patterns in data skilled information management and the use of computer tech able to suggest areas for IT system improvement.
Nurses must ensure the _______ of recorded data.
accuracy
Computerized provider order entry (CPOE)
allows orders to be directly communicated to the appropriate department
Website evaluation criteria
authority, purpose, coverage, currency, objectivity, accuracy, verification
The hospital has implemented a new electronic medication administration record (MAR). What is true about the use of this new tool? a. Verifies medication dosages b. Reduces medication administration errors c. Eliminates the need to count narcotics d. Requires a hard copy of the MAR to be printed
b
Which description is an example of data? a. A print-out of a patient's history and physical examination b. A patient's blood pressure and pulse rate c. The nurse's knowledge of a disease d. A nurse's interpretation of a change in the patient's condition
b
Which descriptions are advantages of health care information technology (IT)? (Select all that apply.) a. Increases health care delivery costs b. Improves communication among providers c. Improves administration functions d. Increases time necessary to document care e. Decreases the safety of providing care
b c
informatics:
broad academic field encompassing artificial intelligence, cognitive science, computer science, information science, and social science
The nurse is assigned to administer medications to a patient on a unit that has just implemented bar code medication administration (BCMA). Which step is proper for the nurse to follow? a. Open the medication packages at the nurses' station. b. Ask the patient to verify his or her address. c. Scan the nurse's ID, the patient's ID, and the code on the medication package. d. Ask the patient to name two patient identifiers.
c
Which description is true about the Nursing Minimum Data Set (NMDS)? a. An admission assessment tool b. A discharge summary c. The core nursing data for collection across all sites d. An organization of nursing diagnoses
c
Which statement is correct concerning the implementation of computerized provider order entry (CPOE)? a. The unit secretary transcribes the physician's orders into the computer. b. The nurse must ensure that orders go to the appropriate departments. c. Physician orders go directly to the appropriate department. d. Handwriting legibility is a major problem.
c
beginner nursing informatic skills
computer, information and web literacy fundamental skills in information management the ability to identify and collect relevant data
data
facts
Computerized Decision Support System (CDSS)
include safe practice alerts and reminders that improve the quality of care
computer literacy
knowledge of computers and the ability to use them efficiently
information
organized data
knowledge
organized information that is meaningful
Advantages to mobile technology in nursing
prevention of medication errors provides instant access to safe dose, compatibility, and pharmacokinetic information that is essential for safe med admin
The International Classification for Nursing Practice (ICNP)
provides a standard that facilitates the description and comparison of nursing practice locally, regionally, nationally and internationally
sign on info and passwords
should never be shared - confidentiality of patient information is a major issue
information literacy
the ability to recognize when info is needed and to locate, evaluate and effectively use the needed info
wisdom
the appropriate application of knowledge
Telehealth or telemedicine
the use of the internet to link medical experts with other clinicians, allowing remote consultations with clear video images and high-fidelity links
