Electronic Health Records
The Institute of Medicine (IOM) recommends core functions that should be performed by an electronic health record (EHR). Which of the following functions do EHRs perform? Select all that apply. Health data Provide work schedules Patient support Administrative processes Order entry management
Health data Patient support Administrative processes Order entry management ------------------------------- Health information and data, order entry management, patient support, and administrative processes are core functions of EHRs. Provider work schedules are not a function of EHRs.
In general, clients value which benefits of the personal health record? Select all that apply. Online access to educational materials Customized care through reminders Collaborative interaction between patients and providers Timely access to personal health information
Customized care through reminders Collaborative interaction between patients and providers Timely access to personal health information Online access to educational materials --------------------------------- From a client perspective, an electronic health record (EHR) system should provide the ability to customize care through appointment reminders and timely access to personal health information. The availability of online educational resources will improve understanding of treatment choices and offer more control over personal health outcomes. Consumers also benefit from technology when there is collaborative interaction between them and their health care providers. The EHR has the potential to have security and privacy breaches, which are not a beneficial to the client, and data should never be publicly accessible.
Drag the correct term to match with the descriptions given below: _______ may be limited to one location or one practice and it may not contain additional health information like nursing notes, insurance and billing details, or lab and diagnostic data. ______ is another term used to describe an EMR. ________ is information about one's health that is designed to be managed by clients. It is designed to be set up, accessed, and managed by individual clients and the information is usually added by the client. Electronic Medical Record (EMR) Electronic Patient Record Personal Health Record (PHR)
Electronic Medical Record (EMR) Electronic Patient Record Personal Health Record (PHR)
A nurse educator is providing nurse continuing education on form updates in the electronic health record (EHR). The educator understands that which of the following are needed to successfully implement the new record? Data and information Deduction and intuition Knowledge and wisdom Awareness and reasoning
Knowledge and wisdom -------------------------------- Knowledge and wisdom are most important in the decision-making process; therefore, the nurse needs to understand not only the forms contained with the EHR and where to document/retrieve data, but knowledge and wisdom to formulate the meaning of information contained in those records. Continuing education on changes in EHRs is helping to maintain competency levels.
As electronic health record implementation expands to include data from multiple healthcare systems and providers, more opportunities for error exist. Which process can affect data integrity? Data mining Data analysis Data downloading System failure
System failure ------------------------------- Data integrity refers to the accuracy and consistency of stored and transmitted data that can be compromised when information is entered incorrectly, deliberately altered, or the system protections are not working correctly or suddenly fail.
A nurse on the medical-surgical unit reviews abnormal lab results in the client's electronic health record (EHR). Which step indicates that the nurse has processed this information appropriately? The nurse waits for the printed copy of the results before calling the provider The nurse reports the results to the provider The nurse contacts the family to report the results The nurse calls the supervisor with the results
The nurse reports the results to the provider ------------------------------- If information obtained from the EHR is abnormal, the nurse should report abnormal information to the provider. It is a HIPAA violation to contact the family without prior authorization from the patient. You do not need a printed copy as the EHR is providing the results. The supervisor does not need to be called with abnormal lab results.
Which system is recommended to address patient safety and reduce errors that occur during the administration of medicines? Electronic medication administration record (eMAR) Barcode medication administration (BCMA) Electronic prescribing (ePrescribing) Personal health administration (PHA)
Barcode medication administration (BCMA) ----------------------------- Barcode medication administration (BCMA) is a method used to address patient safety and reduce errors that occur during the actual administration of medicines. ePrescribing is used by the provider to order the medication (not administer). The eMAR is used to document the medications that are given. Personal health administration is not a method system.
A health care provider is in the client's room documenting in the electronic health record (EHR). A family member is looking over their shoulder to get a view of the documentation. What action should the provider do first to ensure confidentiality and security of the record? Close the electronic health record immediately Continue documenting and provide copies to the family member Continue documenting in the record Take the family member to the nurse's station for assistance
Close the electronic health record immediately ----------------------------------- Close the electronic health record immediately. Health care providers have a responsibility to protect health information, professionally, ethically, and legally. The family member is not an authorized user and has no reason to review documentation in the client's chart.
Which method is used by health care providers to order medications? ePrescribing Barcode medication administration (BCMA) Computerized patient order entry (CPOE) Electronic medication administration record (eMAR)
ePrescribing ---------------------------- ePrescribing is one type of computerized provider order entry (CPOE) used to send medication orders to pharmacies. The eMAR is used to document the medications that are given. Barcode medication administration (BCMA) is a method used to address patient safety and reduce errors that occur during the actual administration of medicines. CPOE is computerized provider order entry, not computerized patient order entry.
Which of the following are examples of evolved systems aimed to protect client safety and help decrease medical errors? Select all that apply. Computerized provider order entry (CPOE) Electronic nurse interventions (ENI) Barcode medication administration (BCMA) Electronic prescribing (ePrescribing) Electronic medication administration record (eMAR) -------------------------------
Computerized provider order entry (CPOE) Barcode medication administration (BCMA) Electronic prescribing (ePrescribing) Electronic medication administration record (eMAR) ------------------------------ The BCMA is a system used to address patient safety and reduce errors that occur during the actual administration of medicines. The eMAR is used to document medications that are given. ePrescribing is used by providers to order medications for clients. CPOE is used to decrease transcription errors during the ordering process. ENI is not a system.
The use of standardized terminology in the electronic health record has a positive impact on client care in which ways? Select all that apply. Increases visibility of health interventions that can be used Enhances data collection to evaluate client care outcomes Improves client care Better communication between healthcare providers Limits use of data information to inform practice -------------------------------------------------
Increases visibility of health interventions that can be used Enhances data collection to evaluate client care outcomes Improves client care Better communication between healthcare providers -------------------------------- The use of standardized terminologies has many advantages. These include better communication between multidisciplinary healthcare providers, increases visibility of health interventions that can be used, improves client care and enhances data collection to evaluate client care outcomes & population health. It improves use, not limits, data information to help inform practice.
Which description best defines the electronic health record (EHR)? An electronic stand-alone database implemented and used in hospitals An electronic version of the traditional paper record created and used by the healthcare provider An electronic record of patient health information created by encounters across multiple settings An electronic version of a patient's medical record used in the clinical setting
An electronic record of patient health information created by encounters across multiple settings ----------------------------------- The EHR is an electronic record of patient health information produced by encounters in one or more care settings. Every person will have a birth to death (and even postmortem) record of health-related information in electronic form from multiple sources, such as physician office visits, inpatient and outpatient hospital encounters, medications, allergies, and multiple other medical services to support care. All other answers refer to a single facility use, which is not the EHR but a potential component of the EHR.
The healthcare organization is implementing electronic order entry that includes drug-allergy alerts. Which actions should the implementation team take to increase user acceptance of the system? Select all that apply. Educate clinicians on how to use the system features Consult physicians to provide deeper insight into data order entry Involve users early in the design, testing, and implementation of the system Plan for continuous safety monitoring Design the new system to support communication and workflow ----------------------------------------------
Educate clinicians on how to use the system features Involve users early in the design, testing, and implementation of the system Plan for continuous safety monitoring Design the new system to support communication and workflow -------------------------------- Early involvement of multidisciplinary providers, not solely physicians, helps to ensure design support, communication and workflow, clinician education, and plans for continuous safety monitoring. A multidisciplinary approach also provides deeper insight into the benefits and issues surrounding computerized provider order entry and some decision support capabilities.
Which system is recommended as a method to decrease transcription errors during the ordering process? Computerized provider order entry (CPOE) Barcode medication administration (BCMA) Electronic prescribing (ePrescribing) Electronic medication administration record (eMAR)
Computerized provider order entry (CPOE) --------------------------------- CPOE is used to decrease transcription errors during the ordering process. The eMAR is used to document the medications that are given. Barcode medication administration (BCMA) is a method used to address patient safety and reduce errors that occur during the actual administration of medicines. ePrescribing is used by the provider to order the medication.
From a client perspective, which is the most valuable reason to use an electronic health record (EHR)? Privacy and confidentiality Care coordination Organizational culture Cost
Care coordination --------------------------- Care coordination is an advantage. Despite the many advances in technology, there are still many issues to resolve associated with costs, data integrity, privacy and confidentiality, organizational culture in the development of an infrastructure to support an EHR. These are barriers to implementation of an EHR.
Demographics, diagnoses, allergies, lab results. Client data to make clinical judgments Ability to manage electronic results of all types, such as lab and radiology reports. Retains both current and historical health information Ability of the clinician to import orders Ability to alert providers to potential drug-drug interactions Online communication amongst multidisciplinary health care team members Patient education and self-monitoring tools Electronic scheduling, billing, and claims management Data collection tools to support reporting requirements and standardized terminology
Health information and data Result Management Order entry management Decision support Electronic communication and connectivity. Patient support Administrative processes and reporting Reporting and population health