Healthcare Information Access and Electronic Health Records: A Comprehensive Guide, Exams of Nursing

Download Healthcare Information Access and Electronic Health Records: A Comprehensive Guide and more Exams Nursing in PDF only on Docsity! Informatic Nursing Exam Questions with correct Answers 1. Which information in an electronic medical record (EMP) helps a nurse plan & manage a patient's post-operative care after open-heart surgery - ANSWER-Provider orders 2. Which information in a patient's electronic medical record (EMA), in addition to the nursing flowsheets & provider orders, helps a nurse plan & manage fluctuation in blood glucose levels - ANSWER-MAR 3.A nurse is planning the care for a patient admitted to the hospital with COVID-19 Which list of information in the electronic medical record (EMR) will help the nurse plan the care for this patient - ANSWER-The patient's laboratory results over the last 72 hours 4. Which clinical note type is exempt from being shared with patients according to the United States Core Data for Interoperability (USC DI) standards - ANSWER- Psychotherapy notes 5. Operating room (OR) staf f are reliant upon a manual white board for patient tracking. Recently, surgeons have complained that the turnaround time between surgical cases has increased & blame the manual tracking system. An informatics nurse recommends expanding use of the existing surgical information system (SIS). Which resolution can improve this workflow issue - ANSWER-Radio frequency identification (RFID) in patient labels 6.An informatics nurse & an emergency nurse are conducting an analysis of a patient admission from the ER - ANSWER- Which tool should these nurses use for a process analysis? SWOT template 7. What is an effective way to reduce the risk of access of electronic protected health information (ePHI) by unauthorized users - ANSWER-Make sure all the users adhere to security & confidential policy set forth by the facility 8. How does a healthcare policy assure access to health information by authorized users - ANSWER-It creates a reliable method to verify the identities of users accessing health information 9. Which statement describes the application of meaningful use - ANSWER-Provider needs to show the use of the Electronic Health Record (EHR) technology 24.Why is it important to control the number of warnings in Electronic Health Record (EHR) - ANSWER-Alert fatigue 25.Which change theory begins with creating urgency - ANSWER-Kotter's Models 26.Which act in 2009 did Meaningful Use (MU) originate - ANSWER-American Recover & Reinvestment Act (ARRA) act in 2009 27.What is the primary concern driving Nursing informatic initiative - ANSWER-Patient safety 28.What can be installed to allow one operation to access another to enable the exchange of data - ANSWER-Integration 29.Which type of chart uses rectangle, oval & diamonds in both - ANSWER- Flowchart 30.What is the intent of the Clinical Decision Support (CDS) System - ANSWER- Providing clinicians with knowledge & person specific information 31.Information may be kept secret to those with an only need to know - ANSWER-What is this? Information privacy is the right to choose the conditions under which information is shared, & to ensure the accuracy of collected information. 32.Which statement defines interoperability - ANSWER-The extent to which systems & devices can exchange data & interpret that shared data. 33.Which two statement defines healthcare informatics - ANSWER- Standardized languages & terminologies to ensure consistent meanings across all settings 34.What is a physical safeguard of ePHI - ANSWER-Lock on hard drive. Facility Access Controls Workstation Use Workstation Security - Device & Media Controls 35.What is a technical safeguard ePHI - ANSWER-Access control. Audit controls. Authentication. 36.Which government agency recommended to use of bar code medication administration - ANSWER-FDA 37.What describes an example of opt-in or opt-out choice regarding the disclosure of personal health information - ANSWER-Your information be sent to another facility 38.What is an important security consideration related to the use of email application to send & receive patient data - ANSWER-Emails have the potential to go to other users 53.What are the ICD ICD10 international classification of diseases - ANSWER-LOINC & SNOMED 54.Provider wants you to change an order what tab would you look under - ANSWER- Order summary tab 55.There are different systems for L&D & the hospital, how would you check for orders & medications - ANSWER-Log out of L&D system & log into the Hospital system 56.What should providers have on their personal mobile devices to protect it from sharing information when stolen - ANSWER- Authentication & encryption 57.Which government agency recommended the use of the barcode medication administration - ANSWER-ONCHIT 58.What are two barriers of adopting the Clinical Decision Support (CDS) in an Electronic Health Record (EHR) - ANSWER-Limited resources & Communication information exchange 59.Which stage of the Systems Development Life Cycle (SDLC) would data be collected from the systems users regarding their analysis - ANSWER-Needs 60.Where is the continuity of care documented - ANSWER- Electronic Health Record (EHR) 61.Which phase of the system life cycle involves using needs assessment to identify the exportation of the system - ANSWER- Needs/Design 62.A physician's group would like to change the current EBP protocol for treating asthma. How should the IN determine validity of the new EBP protocol - ANSWER-Solid clinical trials 63.Which Merit-Based Incentive Payment System (MIPS) merit- based incentive payment system performance replaces Meaningful Use (MU) for physicians - ANSWER- HITCECH act 64.Which area of the Electronic Health Record (EHR) is used to guide a nurse on the task that needs to be completed during the shift - ANSWER- Workflow 65.When developing new clinical workflow, what is one of the first steps that should be taken - ANSWER-Review old progress & old documents 66.You are contacted by a confused user because their legend changes on each screen they go into, would you tell them - ANSWER-The screen symbols change on each screen depending on the activities done 67.Which feature will allow a user to navigate between authorized applications & resources within a single organization - ANSWER- Interface 68.A nurse is entering a verbal medication order & encounters a warning the entry is a duplicate. Which action does the nurse take - ANSWER-Call MD & verify order & MD enter order remotely 69.What are three common reasons for HIPPA violation citations - ANSWER- 1. Lost or stolen unencrypted devices, 2. Social media postings, 3. Taking a patient photo with a personal phone 70.Which item enhances interoperability between organizations when exchanging patient data electronically - ANSWER-Continuity of Care Document (CDD) or Continuity of Care Record (CCR) via direct messaging 71.What plays a primary role in the usability of an Electronic Health Record (EHR) - ANSWER-Clinical workflow & efficiency 72.Stored information in the Electronic Health Record (EHR) can be instantly searched, retrieved, combined, & reported in different ways. What is this describing - ANSWER- Data integrity 73.What is nursing informatics a combination of differentiating it from other nursing disciplines - ANSWER-Nursing, information, & analytical sciences 74.Which two statements define healthcare informatics (HI) - ANSWER-A tool to improve practice & patient care. A field that involves the secure sharing of information 75.Which Electronic Health Record (EHR) challenge can a nurse informaticist help support & change - ANSWER- Analyzing & redesigning workflows 76.Which task is representative of the role of the nurse informaticist - ANSWER-Acting as a superuser 77.At a nursing facility, the recent quality report details only 30% of patients received the influenza vaccine in the prior flu season. Nurses within the medical unit state the result is too low. Which area should an informatics nurse review to understand the quality report results - ANSWER-Electronic Health Record (EHR) charting data 78.What should an informatics nurse do to support the entry of standardized data into an electronic health record (Electronic Health Record (EHR)) - ANSWER-Use patient safety 90.What is a reason to have standardized terminology within a healthcare setting - ANSWER-It provides the effective exchange of information between providers 91.What is the harmonization of terminologies - ANSWER-It fosters interoperability in health information systems 92.Which item describes a basic network code that determines the rules used to create & route packet of data between network devices - ANSWER- Transmission control protocol/internet protocol (TCP/IP) 93.What can be installed to allow a device to connect to the Electronic Health Record (EHR) to enable the exchange of data - ANSWER-An application program interface 94.How does the health information exchange (HIE) improve interoperability within a healthcare organization - ANSWER-It allows patient information to be accessible despite where the patient is receiving care 95.What are connectivity systems - ANSWER-They support the integration of data across different organizations 96.A patient goes to a clinic's office complaining of a cough. The physician orders a chest X-ray & sends the patient to the radiology department. The clinic's admitting department & the radiology office use different information systems. What is used to locate the record in each of these different systems - ANSWER-Master patient index 97.Health systems can be inoperable with other health systems. What are 2 barrier that prevent interoperability - ANSWER-Data blocking. Interface cost. 98.What is considered to be clinical decision support (Clinical Decision Support) within the Electronic Health Record (EHR) - ANSWER-The condition or disease-specific order sets. 99.Unit managers want to be assured nurses are signing completed clinical documentation. What can managers do to determine documentation completion - ANSWER-Randomly run Electronic Health Record (EHR) reports & list noncompliant nurses. 100.Which area of the Electronic Health Record (EHR) is used to guide a nurse on the tasks that need to be completed during the shift - ANSWER- The worklist 101.On admission, a patient reports several allergies. Where does the nurse confirm the documentation of this information - ANSWER-In the patient summary tab or history & physical 102. A nurse has a new order to begin antiarrhythmic medication via IV drip. What needs to be done electronically before this medication can be safely administered - ANSWER-Scan the patient's armband & the medication 103.What is the primary purpose of a clinical decision support system (Clinical Decision Support (CDS) System) - ANSWER-It provides clinicians with suggested care information 104.How is clinical decision support system (Clinical Decision Support (CDS) System) represented in an Electronic Health Record (EHR) - ANSWER- Through alerts & reminders 105.In a healthcare setting, there is resistance towards using a new Electronic Health Record (EHR). The staf f insists the prior system was much faster than navigating this new Electronic Health Record (EHR). Which method should be used to motivate staf f to adopt this Electronic Health Record (EHR) - ANSWER-Involve staf f in the implementation process 106.Which tool highlights the areas in which information technology can improve efficiency & support an interdisciplinary healthcare team - ANSWER- A workflow analysis 107.Which statement defines electronic protected health information (ePHI) - ANSWER-It is information used to specifically identify an individual 108. An informatics nurse is developing a web-based application for patient care. Which statement accurately describes the internet - ANSWER-An unregulated network of networks 109.What is role-based access an example of - ANSWER-Authenticity 110.Which term refers to ensuring confidentiality when sharing a patient's electronic personal health information - ANSWER-Security 111.What advice should be taken to avoid a security breach of protected health information - ANSWER-Open emails only from trusted sources, change passwords as stipulated by the organization, & do no leave ePHI visible in an unsecure area 112.What is the first thing patients should do to access their health records - ANSWER- Use the patient portal email from the healthcare organization to create an account. 113.What represents privacy & security risks for telehealth technology - ANSWER- Patients have the option to use speakerphone in the telehealth apps 114.What are 3 common reasons for HIPPA violation citations - ANSWER-Lost or stolen unencrypted devices. Social media postings. Taking a patient photo with a personal phone. 115. An informatics nurse is on a task force planning committee to ensure data storage measures are safe & accessible. Besides the provider & the client, which group's needs are important to consider - ANSWER-The Joint Commission 116. A restraint committee has been assembled to oversee the need & proper usage of restraints. Which data element would this committee find least useful in this report - ANSWER-Patient allergy history 117.What us a structured method used to analyze serious adverse events - ANSWER- A root cause analysis (RCA) 118.Which form allows stored information in an Electronic Health Record (EHR) to be instantly searched, retrieved, combined, & reported in different ways - ANSWER-Text data 119.What are 3 purposes of using bar code medication administration (BCMA) - ANSWER-It alerts the nurse to drug- drug-interactions. It reduces errors of administration. It supports the 5 rights of medication administration 120.Why was Barcode Medication Administration (BCMA) adopted by healthcare facilities - ANSWER-To prevent medication administration errors 121.What describes the role of decision support within the Electronic Health Record (EHR) - ANSWER-It is designed to assist with timely clinical decision making 122.Which merit-based incentive payment system (MIPS) performance category replaces meaningful use for physicians - ANSWER-Quality of care 123.What do the goals of meaningful use & merit-based incentive programs have in common - ANSWER- Improving quality of care 124.Which government organization oversees the meaningful use 150. Nurse is giving patient education over new medication - ANSWER-Ask patient to repeat info, teach backs 151. Hospital employee falls. Their manager calls & wants an update - ANSWER-Nurse should not provide info 152. HIS system for patient to manage their own stuf f - ANSWER-The app 153. Action that demonstrates data mining to improve patient outcomes - ANSWER- HbA1c 154. Electronically capture patient VS without manually entering - ANSWER- Biomedical device integration 155. What to do when Clinical Decision Support (CDS) System is ignored - ANSWER- Educate staf f on the importance 156. Spouse requests patients medical records - ANSWER- refer family member to medical records 157. Comparing infection rates across state - ANSWER-bar graph 158. Promoting adoption & implementation of telehealth programs - ANSWER- Advocacy 159. Mom calls asking for child's info that was seen at the clinic - ANSWER-Clinic unable to provide the medical records 160. Metrics related to stroke care & compare them across the country in a presentation - ANSWER-Benchmarking 161. Hiker information given to newspaper - ANSWER-Hospital violates HIPAA because they did not follow their guidelines 162. Patient records moved from notes to checkboxes - ANSWER-They reduce clinical documentation time 163. Gap analysis - ANSWER-Transition to a new Electronic Health Record (EHR) 164. Natural disasters - ANSWER-Production software remains in working condition 165. Focus group - ANSWER-Gathering uses to discuss 166.Confirming data accuracy - ANSWER-Triangulation 167.Peripheral biometric device - ANSWER-High BP 168. What is included in meaningful use - ANSWER-Use of electronic prescribing 169. What is the goal of Health Information Exchange - ANSWER- To allow insurance companies & providers to be able to share data 170. What is an effective use of a barcode administration system - ANSWER- Combine it with computerized provider order entry, a pharmacy system, & eMAR 171. Which information would be useful when planning quality care for the next shift - ANSWER-Available critical care beds 172. Barcoding scanning. How it affects inventory with pharmacy - ANSWER-alters ordering & information data 173. What act puts patients in charge of their healthcare records - ANSWER-The 21st Century Cures Act 174. Groups at risk for decreased health literacy - ANSWER-elderly 175. How would an informatics nurse best evaluate other nurses' opinions on technology - ANSWER-survey 176. What is it when a nurse tries to get a patient more involved in the electronic system - ANSWER-autonomy 177. Nurse's role in a power outage - ANSWER-software running 178.Element that is PHI - ANSWER-DOB 179. Main way to keep HIPPA compliance - ANSWER-passwords 180. Best method of Electronic Medical Record charting for nursing - ANSWER- Cascading 181. Physical taking care of a patient whose established care is somewhere else talking about Health Information Exchange - ANSWER-query-based 182. When can you get notes from provider quickly - ANSWER-Health Information Exchange, Query based transfer 183. How to start an admission process when extremely busy - ANSWER- Checklist 184. What would be cause to put someone in isolation - ANSWER-MRSA, Influenza, TB, Covid 185. Legislative act that mandated research become accessible to facilitate better decisions based on evidence - ANSWER- Affordable care act 186. What should a nurse recommend to promote nurse to patient interactions - ANSWER-Encourage patient to eliminate personal technology to increase their attention 187. Role of an informatics nurse specialist is the knowledge & application of state & federal laws. Which role falls outside the scope of practice - ANSWER-Enforce operational procedures 188. Nurse wants to optimize EH software with a goal of decreasing documentation time - ANSWER-Surveys 189. Cost effective documentation - ANSWER-Records procedure & patient response directly into the work computer 190. Situation where nurse carries out an Health Information Exchange - ANSWER-NP reviews patient records/read dx test results from remote facility 191. A blood pressure cuf f or peripheral device linked to the computer or health system is what kind of technology - ANSWER- Biomedical device integration 192. Barriers to using health informatics to improve health literacy - ANSWER- Informatics utilizes technology as a foundation, but technology isn't always available to people with lower health literacy 193. Training docs in the PACS into the Electronic Health Record (EHR). Which will require the nurse to create training documents - ANSWER- Accessing & reviewing X- rays 194. What is one example of data that is tracked for the purpose of improved quality - ANSWER-Patient falls 195. Data visualization of oncology patient length of stays - ANSWER-Line graph Refers to the collection of policies, standards, processes, & controls applied to an organization's data - ANSWER-Data governance 196. Universal precautions approach to health literacy - ANSWER- 222. American Recover & Reinvestment Act (ARRA) - ANSWER- 2009 223.What is purpose for benchmarking - ANSWER-Statistics 224. Patient discharge teaching most effective - ANSWER-Ask patient to teach back what he learned 225. In emergency doctor needs patients data from different state. Does doctor need patient permission to get it - ANSWER- No 226. Two nurses are in the cafeteria talking about lab reports & they commit HIPAA violations what is the action - ANSWER-Fines 227. Medication alert pops up & what system is alerting - ANSWER- Clinical Decision Support (CDS) System 228. The hospital announced its integration engine has stopped functioning. What does this mean for system interoperability throughout the organization - ANSWER-Manually chart the vital signs. 229. Monitor patient glucose level you need - ANSWER-nurse flow sheets 230. Alt enzymes liver - ANSWER-Tell about liver damage 231.What is barrier to use biometrics - ANSWER-Financial 232. Computerized Provider Order Entry (CPOE) - ANSWER- provider enters orders 233. Patient with influenza B. How do you know to start respiratory precautions - ANSWER-Lab 234. Community facility the doctor had been saying the mom was calling the office to get a copy of the records of Daughter, moms calls to find out info about medical record - ANSWER-Don't say anything 235. Nurse send message to doctor "Mr smith, bp 84/74. 54" - ANSWER- Not enough info for doctor to prescribe treatment 236. A hospital has a surgical department that uses a different Electronic Health Record (EHR) from the main EHR (Integrated). When a physician input an order in the surgical department, how would you ensure that it is in the main EHR - ANSWER-Chart in one & it will go into Electronic Health Record (EHR). 237. During which phase of the systems development life cycle should a system be activated to effectively be used by end users - ANSWER- Implementation. 238. Process that uses software to uncover relationships within large data sets via the use of artificial intelligence, statistical - ANSWER-Data mining 239. Statewide health information exchange responsible for implementing interoperability standards. What is the name of state level Health Information Exchange - ANSWER-Health Level 7. 240. What is the mission of the Health Level Seven (HL7) organization - ANSWER-To provide a comprehensive framework & related standards for the exchange, integration, sharing, & retrieval of electronic healthcare information. 241. What is also considered to be Clinical Decision Support (CDS) within the Electronic Health Record (EHR) - ANSWER-The condition/disease specific order set. 242. What can be installed to allow one operation to access another to enable the exchange of data - ANSWER-An application program interface. 243. Installed to allow on operation to access another - ANSWER- Interface 244. Workflow analysis - ANSWER-Also known as process analysis, involves identifying, prioritizing & ordering the tasks & info needed to achieve the intended result of a clinical or business process. Workflow analysis mitigates these rights & increases the changes for success in an IT implementation. 245. Homeless man - ANSWER-Haemophilus influenzae (bacterial flu) Haemophilus influenzae type b (Hib) Before the Hib vaccine, influenzae was the leading cause of bacterial meningitis in children. x-Ray of the chest needed 246. Homeless man IV drug user - ANSWER-Find in the EMR which information helps you put him in isolation. 247. TV & mercy in western word - ANSWER-Answer is mercy 248. Treatment of patient related to blood pressure measures - ANSWER- Medication administration 249. Fluctuation in glucose - ANSWER-Medication administration 250.Constipation - ANSWER-intake & output 251. Discharge planning - ANSWER-Starts on admission 252. Discharge papers - ANSWER-Ask the patient what works best for him 253. Discharge teaching paper patient with diabetes - ANSWER- Important what the time of day 254. Quality of care - ANSWER-Benchmark (can be used to evaluate patient & quality performance & compares services they can have) 255. Single event & doing root cause analysis - ANSWER- Fishbone 256.Stroke patient & analysis - ANSWER- Statistical, fishbone 257. ER trying to improve quality of care & decreased waste time. Nurse recognizes a problem & thinks of a solution - ANSWER- Planning phase when the nurse recognizes a problem & solution 258. Rapid dictation advantages of template based charting - ANSWER- They are available immediately 259. Merit-Based Incentive Payment System (MIPS) for Doctor - ANSWER- 90,000 & 200 patients 260. LOINC - ANSWER-LAB 261. Health Level 7 - ANSWER-Health Information Exchange enhance interoperability 262. To create an informatics culture - ANSWER-Assess current state to determine gaps 263. Which informatics solution assists in ensuring TASKS are accomplished - ANSWER-Electronic Checklist 264. Which entity is required by HIPPA to remove identifying info before sharing publicly - ANSWER-Billing company 265. Alert for medication from - ANSWER-Clinical Decision Support (CDS) System. ANSWER-PRN Meds 291. Where to look to further evaluate & manage patient with significant BP - ANSWER- Intake & Output 292. Computerized Provider Order Entry (CPOE) for advocating quality of care - ANSWER-electronic prescriptions, physician orders & prescriptions 293. Data Mining - ANSWER-Improve patient outcome & quality (falls over last year) had the word NUMBER in the answer 294. Benchmark - ANSWER-Clean & accurate, quality of care, can be used to evaluate patient safety, quality performance, measure & compare services, improve performance, sets standards of excellence, identifies learning gaps (pt falls) 295. Covid graphing - ANSWER-scatterplot 296.Statistical analysis - ANSWER-stroke patient 297. Benefit of rapid dictation - ANSWER-front-end dictation can be edited & file immediately available upon completion. Eliminate human errors & more accurate documentation. 298. Planning - ANSWER-Nurse recognizes a PROBLEM & thinks of a SOLUTION (1stphase) 299. Analysis - ANSWER-New technology going to roll out & staf f is deciding what can make it better 300. Maintenance - ANSWER-Debugging, fixes bugs 301. Informatics Nurse receives multiple requests most important - ANSWER-Workflow & cost saving 302. Review ICU fall risk - ANSWER-Different reviewer's conduction research 303.Benefit of Internet/externet - ANSWER-Improve communication & teamwork 304. Nurse asked to conduct secure data analysis - ANSWER- Use secure server 305. Nurse asked to be a part of a study - ANSWER-Provide de- identified data 306. Ethical/legal issue with rural hospital & tele-radiology - ANSWER-State licensing issue 307. HITECH - ANSWER-Financial 308. Institute Isolation - ANSWER-Path report to confirm pathogen 309. Triangulation - ANSWER-Analyzing a single piece of data in multiple ways 310.Busy ER what can nurse do to help - ANSWER- Nurse start admission process 311. Clinical data enters the data warehouse in a de-identified state - ANSWER- Ensures data is clean & accurate 312. Researcher wants patient data for a journal - ANSWER-De- identified & patient consent 313. Benefit of MD using Computerized Provider Order Entry (CPOE) & DSS - ANSWER-Alerts when ordering Viagra (sildenafil) when patient is taking a cardiac med. 314. RN needs to override a med which one would she NOT override - ANSWER- Comfort care patient with 2 new orders 315. Clinical Decision Support/Clinical Decision Support (CDS) System - ANSWER- Evidence Based Practice 316. Identifiable Patient Information is also called - ANSWER- Personal data, personal information & PII 317. Implementing new process & nurses are reluctant what is important - ANSWER- improve workflow & expertise 318. Staf f is resistance to Tele-ICU. What are the benefits - ANSWER- resources & expertise 319. Informatics Nurse needs to assess new progress - ANSWER- observation with interview 320. Doctor use RFID for which purpose - ANSWER- Improve documentation time or Improve access to documentation 321. Which stage of cycle nurse makes new suggestions - ANSWER-Need assessment 322. Random coworker calls & asks if his coworker there or will come back to work - ANSWER-Don't give information. 323. Plan/manage treatment - ANSWER-Providers order 324. Patient transferring from the ED to the ICU. Info comes from -