Informatics Study Qs
The specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice is A. Computer science. B. Health informatics. C. Health information technology. D. Nursing informatics.
D Rationale The specialty is nursing informatics. Computer science is a branch of engineering that studies computation and computer technology, hardware, software, and the theoretical foundations of information and computation techniques. Health informatics is a discipline in which health data are stored, analyzed, and disseminated through the application of information and communication technology. Health information technology is an application of information processing that deals with the storage, retrieval sharing, and use of health care data, information, and knowledge for communication and decision making.
On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? A. Information technology. B. Electronic health record. C. Personal health information. D. Administrative information system.
B Rationale This is an example of an electronic health record. The electronic health record is an electronic record of patient health information generated whenever a patient accesses medical care in any health care delivery setting. In this question you are able to access information about the patient from the current hospitalization and from four previous times when the patient accessed care.
Match the correct entry with the appropriate SOAP (Subjective—Objective—Assessment—Plan) category. 1. S a. Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device. 2. O b. "The pain increases every time I try to turn on my left side." 3. A c. Acute pain related to tissue injury from surgical incision. 4. P d. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.
1b 2d 3c
Consequences for a staff nurse related to the use of health informatics include A. Clinical decision support tools. B. Confidentiality of health data. C. Decreased cost of health care. D. Personal health record.
A Rationale The availability of clinical decision support tools at the point of care would be a consequence for a staff nurse. Confidentiality of health data affects patients; a nurse might be involved in ensuring the security and privacy of health information and exchange. A decreased cost of health care would affect a patient; a nurse's ability to reduce duplication of services will influence costs. Adopting a personal health record would be a consequence for a patient.
When discussing the purposes of nursing health care informatics with a nurse during orientation, a nurse educator would be concerned if the nurse orientee said a primary purpose would be to A. Develop a data management system. B. Improve disease tracking. C. Improve a health provider's work flow. D. Increase administrative efficiencies.
A Rationale Data management is an exemplar of health informatics, but it would not be a primary purpose for a bedside nurse. The nurse educator would use this incorrect response to plan additional teaching about the primary purposes of health care informatics for the staff nurse. Purposes of information health technology include improving health provider work flow, improving health care quality, preventing medical errors, reducing health care costs, increasing administrative efficiencies, decreasing paper work, and improving disease tracking.
Which of the following concepts would a nurse consider to have the strongest links to technology and informatics? (Select all that apply): A. Clinical judgment. B. Ethics. C. Leadership. D. Professionalism. E. Safety.
A,B,C,E Rationale Professionalism refers to the attributes and behaviors of a nurse as a representative of the nursing profession and as a health care professional. There are many interrelated concepts that bear some relationship to health information technology and health informatics, including data, information, knowledge, wisdom, trust, health, health care, meaningful use, bandwidth, and interoperability. Others found in this book include clinical judgment, leadership, communication, collaboration, safety, evidence, care coordination, health care quality, ethics, health policy, and health care law.
You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) A. The patient's name, age, and admitting diagnosis B. Allergies to food and medications C. Your evaluation that the patient is "needy" D. How much the patient ate for breakfast E. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol
Answer: 1, 2, 5. During change of shift report, include essential background information such as the patient's name, age, diagnosis, and allergies. Also include response to treatments such as response to pain-relieving measures. Information about how much the patient ate for breakfast is not necessary. This information is in the chart if the nurse really needs to know. Do not include critical comments about your patients.
A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A. "CPOE reduces transcription errors." B. "CPOE reduces the time necessary for health care providers to write orders." C. "Health care providers can write orders from any computer that has Internet access." D. "CPOE reduces the time nurses use to communicate with health care providers."
Answer: 1. CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly.
You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: A. Documented medication given by another nursing student. B. Included the date and time of all entries in the chart. C. Stood with his back against the wall while documenting on the computer. D. Signed all documentation electronically.
Answer: 1. Nurses only document the care they provide; entries in the chart need to be dated, timed, and signed.
While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: A. The nurses forgot to document on the pulmonary system. B. The nurses were charting by exception. C. The computer is not working correctly. D. The physician does not have authorization to view the nursing assessment.
Answer: 2. Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. There is no need for further documentation unless the pulmonary assessment changes and is no longer within normal limits.
A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: A. Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report. B. Gives a newly ordered medication before entering the order in the patient's medical record. C. Reads the orders back to the health care provider after receiving them and verifies their accuracy. D. Asks the preceptor to listen in on the phone conversation.
Answer: 2. Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur.
A patient asks for a copy of her medical record. The best response by the nurse is to: A. State that only her family may read the record. B. Indicate that she has the right to read her record. C. Tell her that she is not allowed to read her record. D. Explain that only health care workers have access to her record.
Answer: 2. Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the patient has given permission.
You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet? A. The new federal laws require that teaching sheets be e-mailed to patients after they are discharged. B. You need to use words the patients can understand when writing the directions. C. The form needs to be given to patients in a sealed envelope to protect their health information. D. The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.
Answer: 2. Patients need to be able to understand information that you provide to them; ensure that written instructions are provided at a level that matches the patients' reading ability.
A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? A. Electronic health record B. Clinical documentation C. Clinical decision support system D. Computerized physician order entry
Answer: 3. A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user.
What is an appropriate way for a nurse to dispose of printed patient information? A. Rip several times and place in a standard trash can B. Place in the patient's paper-based chart C. Place in a secure canister marked for shredding D. Burn the documents
Answer: 3. Confidential patient information should be shredded. It is generally collected in large secure containers and shredded at scheduled times.
You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response? A. HIPAA allows all hospital staff access to your medical record. B. HIPAA limits the information that is documented in your medical record. C. HIPAA provides you with greater control over your personal health care information. D. HIPAA enables health care institutions to release all of your personal information to improve continuity of care.
Answer: 3. HIPAA provides patients with control over who receives and accesses their medical records. It does not allow uncontrolled access to the medical records. HIPAA also does not dictate what must be documented in the patient's medical record.
As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? A. The patient has a defiant attitude and is demanding his test results. B. The patient appears to be upset with his nurse because he wants his test results immediately. C. The patient is demanding and complains frequently about his doctor. D. The patient stated that he felt frustrated by the lack of information he received regarding his tests.
Answer: 4. Answer 4 is a nonjudgmental statement regarding the nurse's observations about the patient. Answers 1 and 3 are judgmental, and information in the medical record should be factual and nonjudgmental. Answer 2 needs to be more specific regarding the reason for the patient's concern.
Which of the following charting entries is most accurate? A. Patient walked up and down hallway with assistance, tolerated well. B. Patient up, out of bed, walked down hallway and back to room, tolerated well. C. Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. D. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.
Answer: 4. Answer 4 provides the most accurate, objective information for the chart.
A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? A. Avoid rushing when charting an entry. B. Use correction fluid to remove the entry. C. Draw a single line through the statement and initial it. D. Enter only objective and factual information about the patient.
Answer: 4. Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record.
To address a goal of improving the health of populations, a nurse is most likely to use informatics in the domain of A. Certified clinical information systems. B. Clinical health care informatics. C. Public health/population informatics. D. Translocational bioinformatics.
C Rationale: Public health/population informatics is the domain that relates information, computer science, and technology to public health science to improve the health of populations; this domain would provide data for a nurse working with communities. Certified clinical information systems (CISs) refers to the tools used for achieving quality outcomes, including electronic health records, clinical data repositories, decision support programs, and handheld devices, not to the data. Clinical health care informatics and the subset nursing informatics provide for the development of direct approaches to patients and their families that can be used by a staff nurse to promote quality patient care. Translational bioinformatics refers to the research science domain where biomedical and genomic data are combined; it is a new term that describes the domain where bioinformatics meets clinical medicine and generally applies to health care research rather than direct patient care.
3 The nurse documents assessment findings in an electronic documentation system in narrative format. Discuss the problems associated with this style of documentation
Narrative documenting often leads to information that is repeated in the medical record. This system is also time consuming and requires the reader to sort through a lot of information to locate data needed for patient care.