Informatics
A client asks the nurse how to obtain the client's lab results and history of visits. Which informatics application should the nurse recommend? A. Telehealth B. Patient portal C. Clinical decision support D. Insurance billing summary
patient portal Rationale: A patient portal allows clients to access parts of the electronic health record, schedule appointments, and communicate with providers. Telehealth describes the assessment and care being provided remotely through the use of technology. Clinical decision support is the use of data to trigger alerts and recommendations for treatment options. An insurance billing summary is not a useful tool in this situation.
Which factor should the nurse exclude as a benefit of electronic medical records? A. Recognizing the need for vaccines B. Tracking client data over time C. Identifying the need for mammograms D. Notifying clients of upcoming appointments
Notifying clients of upcoming appointments Rationale: Tracking client data over time, identifying the need for vaccines, and identifying the need for mammograms are all benefits of electronic medical records. Notifying clients of upcoming appointments is not a benefit of electronic medical records.
The government affects the process of transitioning to the use of electronic medical records (EMRs). Which statement by the nurse describes this process? A. "The Office of the National Coordinator for Health Information Technology authorizes financial reimbursement." B. "The Office of the National Coordinator for Health Information Technology is the sole agency overseeing transitioning to EMRs." C. "The Centers for Medicare and Medicaid Services monitors achievement of meaningful use objectives." D. "The Centers for Medicare and Medicaid Services monitors the transition of EMRs at the federal level."
"The Centers for Medicare and Medicaid Services monitors the transition of EMRs at the federal level." Rationale: On a federal level, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) oversee the process of transitioning to the use of EMRs. The ONC monitors the achievement of meaningful use objectives, which are reported to the CMS to authorize financial reimbursement.
The nurse is discussing a method of measuring nursing care and its impact on the client, as well as validating the benefits and actual costs of nursing care. Which is the nurse discussing? A. Nursing research B. Clinical decision support systems C. Uniform language D. Evidence-based practice
Uniform language Rationale: Benefits of using uniform language include a better capability to measure nursing care and its impact on the client and to validate the benefits and actual costs of nursing care to administrators. Uniform language also allows easier retrieval of evidence-based information. Clinical decision support systems are tools designed to supplement decision-making processes during and after client care. Point of care refers to the nurse's ability to perform client interventions or testing using portable devices near the client. Evidence-based practice is reflective of research.
The nurse is describing applications of telehealth. Which activity should the nurse include? (Select all that apply.) A. Watching clients perform a return demonstration of skills B. Using dual webcams to visually assess the client's condition C. Managing acute and chronic conditions of the client D. Allowing clients to consult with healthcare providers regardless of location E. Having the client meet with a virtual health coach
Watching clients perform a return demonstration of skills Using dual webcams to visually assess the client's condition Managing acute and chronic conditions of the client Having the client meet with a virtual health coach Rationale: Applications of telehealth include allowing the client to meet with a virtual health coach, managing acute and chronic conditions, using dual webcams to visually assess the client's condition, and watching clients perform a return demonstration of skills. Not all states issue telemedicine licenses that permit healthcare providers to practice telehealth across state lines. As such, not every healthcare provider can consult with out-of-state clients via telehealth.
The nurse is describing geographic information system (GIS) technology. Which statement should the nurse exclude? A. "It is dependent on global positioning systems." B. "It is useful in the plotting of lifestyle choices." C. "It is limited to use strictly within healthcare." D. "It is useful in analyzing location-based data."
"It is limited to use strictly within healthcare." Rationale: Geographic information system (GIS) technology has been used both inside and outside of healthcare. To capture geographical data, GIS relies on satellite imaging and global positioning systems (GPSs). Applications of GIS may include analyzing population- or location-based data, such as disease transmission, obesity rates, cancer rates, trends in diseases, and environmental data. GIS can also be used to plot and analyze lifestyle choices, such as improper nutrition, tobacco use, and physical activity rates.
The nurse is describing the function of a Global Location Number (GLN) as it relates to standardization. Which statement is accurate? A. "A GLN helps identify the room assignments of clients admitted to the healthcare facility." B. "A GLN replaces the custom item numbers of the healthcare institution's products." C. "A GLN makes it easier for the healthcare institution to be located." D. "A GLN increases the ease of locating supplies in the healthcare institution's storage facility."
A GLN makes it easier for the healthcare institution to be located." Rationale: The materials management and supply chain community sought standardization through measures including issuing each facility a GLN instead of an account number, which improves the ease of locating healthcare institutions. Standardization strategies also included assigning each product used in a healthcare facility a Global Trade Item Number (GTIN) as opposed to a custom item number.
Which statement should the nurse use to explain point-of-care services? A. "Use of computerized medical records is a barrier to point of care." B. "Point of care may increase the wait time for receipt of certain laboratory test results." C. "An intervention occurring near the client using a handheld device is called point of care." D. "Increased efficiency is an unexpected outcome when using point of care."
An intervention occurring near the client using a handheld device is called point of care." Rationale: Point of care refers to interventions or tests that involve the use of portable, transportable, or handheld devices near the client. This model eliminates the need to wait for certain laboratory test results. The electronic health record also allows for charting at the point of care, which, in turn, results in increased efficiency.
The nurse is discussing the use of electronic health records (EHRs) when providing client discharge teaching. Which information should the nurse include? (Select all that apply.) A. Client teaching materials are more accurate due to standardization. B. Standardized teaching materials should not contain web links. C. Many EHR systems offer educational information in various languages. D. The nurse may choose not to personally review standardized teaching materials with the client. E. Before using standardized teaching materials, the nurse should assess the client's ability to read.
Client teaching materials are more accurate due to standardization. Many EHR systems offer educational information in various languages. Before using standardized teaching materials, the nurse should assess the client's ability to read. Rationale: Standardization of the EHR allows clients in any healthcare setting to receive the same educational material. When the educational material is current and evidenced based, client teaching is more accurate and meaningful. Some material may provide links to websites for additional information. Many EHR systems offer educational information in different languages, as well. When using standardized teaching material, nursing responsibilities still include reviewing the information in person with the client or family member and assessing the client or family member's ability to read and understand the information.
The nurse is preparing an in-service about the benefits and recommended uses of the electronic health record. Which topic should the nurse include? (Select all that apply.) A. Delivering sensitive test results to clients using online systems B. Documenting client responses to nursing interventions C. Notifying healthcare providers about acute changes in clients' conditions D. Inputting data related to administering client medications E. Reducing time spent away from the client's bedside
Documenting client responses to nursing interventions Inputting data related to administering client medications E. Reducing time spent away from the client's bedside Rationale: Most electronic health records (EHRs) allow nurses to input a wide range of data without leaving the client, including vital signs, medication administration records, assessment notes, and responses to nursing interventions. Acute changes in the client's condition still require a phone call to the healthcare provider. Sensitive test results, such as pathology reports, should still be delivered in person by the healthcare provider and not discovered by the client online
Which term should the nurse use to describe the computerized medical record? (Select all that apply.) A. Administrative information system B. Electronic health records system C. Clinical information system D. Clinical decision support system E. Computerized patient record
Electronic health records system Computerized patient record Rationale: Other terms commonly used to describe the computerized medical record (CMR) include electronic health records system (EHRS), electronic medical record (EMR), electronic health record (EHR), computerized patient record (CPR), patient medical records software (PMRS), and personal health record (PHR). Clinical decision support systems are a type of artificial intelligence that analyze data and provide information about evidenced-based practices. A clinical information system allows multiple disciplines to simultaneously access the client's chart and record data that can be viewed and analyzed by multiple healthcare providers in real time. An administrative information system provides support and management for the business aspects of health care
The nurse is teaching a class about the Office of the National Coordinator for Health Information Technology and meaningful use objectives. Which item should be included? (Select all that apply.) A. Controlling and monitoring clients' healthcare choices B. Ensuring the security and privacy of protected medical information C. Reducing health disparities by improving safety and quality of care D. Engaging clients and their families in the client's care E. Improving care coordination to improve client outcomes
Ensuring the security and privacy of protected medical information Reducing health disparities by improving safety and quality of care Engaging clients and their families in the client's care Improving care coordination to improve client outcomes Rationale: The Office of the National Coordinator for Health Information Technology (ONC) monitors the achievement of meaningful use objectives, which are reported back to the Centers for Medicare and Medicaid Services (CMS) in order to authorize financial reimbursement. Meaningful use objectives include improving care coordination, reducing health disparities among U.S. citizens by improving the safety and quality of care, ensuring the security and privacy of protected medical information, and engaging clients and their families in the client's care. Meaningful use objectives do not include controlling and monitoring clients' healthcare choices.
The nurse is planning a webinar about the benefits of using uniform language in the electronic health record. Which information should the nurse include? (Select all that apply.) A. It enhances the individual nurse's decision making at the point of care. B. It reduces the emphasis on the need for critical thinking when providing client care. C. It helps healthcare organizations validate the benefits and costs of nursing care. D. It decreases nurse educators' ability to teach vital concepts related to the nursing process. E. For healthcare organizations, it facilitates the measurement of nursing care's impact on the client.
It enhances the individual nurse's decision making at the point of care. It helps healthcare organizations validate the benefits and costs of nursing care. For healthcare organizations, it facilitates the measurement of nursing care's impact on the client. Rationale: Using uniform language in the electronic health record (EHR) enhances nurse educators' ability to tailor curricula to teach vital concepts related to the nursing process. Uniform language also allows healthcare organizations to more effectively measure nursing care and its impact on the client, as well as to validate the benefits and actual costs of nursing care to administrators. Additional benefits of using uniform language include facilitating decision making and critical thinking at the point of care.
Which statement by the nurse describes the ideal use of clinical decision support systems in the electronic health record? A. "It should have no impact on the quality of client care." B. "It should reduce the need for critical thinking in nursing." C. "It should facilitate the use of nursing research in client care." D. "It should eliminate certain steps from the nursing research process."
It should facilitate the use of nursing research in client care." Rationale: A clinical decision support system is a type of artificial intelligence that analyzes data and provides information about evidence-based practices. The use of electronic health records (EHRs) that contain clinical decision support systems should promote best practices through incorporating nursing research, as well as by making it easier to use current nursing research at the point of care. Although there is no substitute for sound nursing judgment, clinical decision support systems may improve client safety and quality of care. Even with advanced technology and information access, the steps of the nursing research process should remain the same.
The nurse is using the electronic health record (EHR) to document client information. Which information is communicated to the healthcare provider through the EHR? (Select all that apply.) A. Medications administered to the client B. Acute changes in the client's condition C. Client vital signs D. Assessment notes on the client's condition E. Client responses to nursing interventions
Medications administered to the client Client vital signs Assessment notes on the client's condition Client responses to nursing interventions Rationale: Most EHRs allow nurses to input a wide range of data without leaving the client, including vital signs, medication administration records, assessment notes, and responses to nursing interventions. The EHR is not a substitute for in-person and other means of verbal communication with peers, fellow health professionals, and especially the client. Acute changes in the client's condition still require a phone call to the healthcare professional.
The nurse is discussing useful functions of the electronic health record for case managers. Which function should the nurse include? A. Recommendation for isolation B. Notification of change in medication C. Notification that a client met criteria for discharge D. Update of a prescription drug formulary
Notification that a client met criteria for discharge Rationale: A case manager coordinates a client's total care, and being able to determine that a client has met criteria for discharge is a notification to a case manager that the discharge plan that began at admission is to be implemented. A recommendation for isolation and notification of a change in medication would be most helpful to the direct client care team. An update of a prescription drug formulary is useful for a case manager, but the discharge criteria notification is far more beneficial.
A nurse is discussing the effects of using uniform language in the electronic health record (EHR). Which statement should the nurse include? A. "Most computerized systems use uniform language to integrate nursing terminologies into the EHR." B. "Documentation is more challenging when computerized systems incorporate uniform language." C. "Retrieval of evidence-based information about client care is easier when using a uniform language." D. "The use of uniform language will increase the number of steps in the nursing research process."
Retrieval of evidence-based information about client care is easier when using a uniform language." Rationale: Most computerized systems do not provide a way to integrate nursing terminologies directly into the EHR, which is reflective of a barrier to the use of uniform language in research environments. The use of uniform language combined with the ability to query EHRs should make nursing research easier. However, the steps of the nursing research process should remain the same. For the nurse researcher, using uniform language increases the ease of documentation and retrieval of evidence-based information about client care.
The nurse is listing what clients may perform through patient portals. Which component should the nurse include? (Select all that apply.) A. Reviewing lab results B. Making changes to the electronic health record C. Scheduling appointments D. Requesting an official copy of their records E. Sending messages to a provider
Reviewing lab results Scheduling appointments Sending messages to a provider Rationale: A patient portal allows clients to see parts of the medical record and to schedule appointments. Many also have the ability to send messages and requests to the care team. Clients are not able to make changes to their medical records through a patient portal. Also, requesting an official copy of records is not a function of the patient portal.
The nurse wants to ensure that a safe level of narcotic medications is being prescribed for a client who may have an issue with addiction. Which informatics application should the nurse use? A. The client's health history and records B. Clinical decision support C. Statewide prescription database D. Telemedicine
Statewide prescription database Rationale: A statewide database that tracks prescription narcotics can help ensure that clients are not given unsafe amounts of pain medications. This process can also identify specific providers who may be issuing prescriptions for narcotics in an irresponsible manner. Telemedicine is the remote access of healthcare services through technology. Clinical decision support describes the use of data from an electronic health record (EHR) to identify best practices. A review of medical records is always advisable, but this is not an application of informatics.
The nurse is discussing how quality metrics are used to meet and document the requirements of regulatory agencies for reimbursement and accreditation. Which component should the nurse include? (Select all that apply.) A. Trauma center certification B. Client demographic documentation C. Insurance reimbursement D. Employee background checks E. Stroke center certification
Trauma center certification Insurance reimbursement Stroke center certification Rationale: The availability of quality metrics simplifies the process of meeting and documenting the requirements set forth by regulatory agencies that govern healthcare organizations' eligibility for reimbursement and accreditation in numerous areas. Those areas include certification as a trauma center or stroke center and reimbursement by insurance plans that require adherence to policies issued by The Joint Commission and the Centers for Medicaid and Medicare Services. Quality metrics do not apply to documenting client demographics or conducting employee background checks.
