Final Exam: Point of Care, Health Tech, and Nursing Informatics, Exams of Nursing

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NR 599 / NR599 Comprehensive Final Exam (POC) Point of Care - ANSWER: Testing and diagnosis at the patient's side and can be conducted anywhere the patient is, such as the home, physician office, ambulance, or hospital bedside 3 key elements to medical decision making - ANSWER: risk, data, and diagnosis Administrative Data - ANSWER: Include billing information derived from insurance claims, inpatient discharges (or hospital bills), and outpatient visits. alarm fatigue - ANSWER: multiple false alarms by smart technology that cause workers to ignore or respond slowly to them Alert Fatigue - ANSWER: Main challenge to effective implementation of CDS Tools American Nurses Association- Code of Ethics for Nurses with Interpretive Statements. - ANSWER: provides specific guidance for ethical decision making and provides a valuable framework that can be used when working with HIT American Recovery and Reinvestment Act of 2009 (ARRA) - ANSWER: -provided funds to government agencies for improving information- technology systems; -provisions include the right for every person to receive an electronic copy of their EHR and to have a copy of their EHR transmitted to a party that they designate Autonomy - ANSWER: The right to choose for himself or herself; respecting the clients opinions, perspectives, values and beliefs. Beneficence - ANSWER: Actions performed that contribute to the welfare of others; Action of doing good or right by and for the patient. benefits of using a data set - ANSWER: efficiency accuracy and effectiveness resulting in improved patient care and outcomes has an effect on cost information visibility and transformation / health care reform Bioethical Standards - ANSWER: Autonomy, freedom, veracity, privacy, beneficence, and fidelity are maximally appropriate to the health care setting. classification system - ANSWER: assistant that captures categories that are used for cost or clinical documentation clinical decision support systems - ANSWER: a computer-based program designed to assist clinicians in making clinical decisions by filtering or integrating vast amounts of information and providing suggestions for clinical intervention Clinical Support Tools - ANSWER: -Found in EHR software that when applied effectively, can enhance patient care quality and outcomes, improve efficiency, and help to ensure regulatory compliance. -Process designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient specific interventions, assessments, recommendations, or other forms of guidance for clinicians, patients, and others involved in care delivery. cognitive science - ANSWER: how the human mind works from an information processing perspective Components of Risk Based E/M Coding - ANSWER: History; Physical; Medical Decision Making computer science - ANSWER: studies the theory underpinning information and computation and their implementation and computer systems Computer-aided Translators - ANSWER: Language translation in which a human translator uses computer hardware to support and facilitate the translation process. HITECH Act of 2009 - ANSWER: -Provided incentive payments to hospitals and healthcare providers to adopt health IT. human technology interface - ANSWER: The hardware and software through which the user interacts with any technology. for example computers patient monitors and telephones. The human technology interface addresses the user's ability and the technologies functionality to complete the task demand. ICD-10 Codes - ANSWER: -Alphanumeric codes used by doctors, health insurance companies, and public health agencies across the world to represent diagnoses. -Shorthand for the patient's diagnosis , which are used to provide the payer information on the necessity of the visit or procedure performed information literacy - ANSWER: The ability to identify when information is needed as well as the skills to find evaluate ineffectively use the same information information literacy competency standards for nursing - ANSWER: able to recognize when information is needed and having the ability to locate evaluate and use effectively the needed information information science - ANSWER: The retrieval and management of information as well as human computer interaction international statistical classification of diseases and related health problems ( ICD ) - ANSWER: ICD is used as a standard terminology (ST) parentheses not always accepted knowledge - ANSWER: The awareness and understanding of a set of information and ways that information can be made useful to support a specific task or arrive at a decision meaningful use - ANSWER: the use of certified electronic health record technology to achieve health and efficiency goals, with a financial incentive from Medicare and Medicaid meaningful use - ANSWER: using technology and health information to increase the quality of care delivered Medical Billing - ANSWER: process of submitting and following up on claims made to a payer in order to receive payment for medical services rendered by a healthcare provider Medical Coding - ANSWER: use of codes to communicate with payers about which procedures were performed and why . Medical Decision Making (MDM) - ANSWER: 1 of 3 components to establishing E/M codes; way of quantifying the complexity of thinking that is required for the visit. Medical Devices - ANSWER: Any equipment, instrument, implant, material, or apparatus used for the diagnosis, treatment, or monitoring of patients. mHealth (Mobile Health) - ANSWER: -The practice of medicine and public health supported by mobile devices such as mobile phones, tablets, personal digital assistants and the wireless infrastructure. -The use of wireless communication to support efficiency in public health and clinical practice. Mobile Medical Applications (Apps) - ANSWER: -Accessories to a regulated medical device or are a software that transforms a mobile platform into a regulated medical device. -Facilitates mHealth National Prevention Strategy: America's Plan for Better Health and Wellness - ANSWER: comprehensive plan that sets forth evidence-based and achievable means for improving health for all Americans at every stage of life. These efforts are designed to stop disease before it starts and to create strategies for a healthy and fit nation, recognizing that prevention must be part of daily life. Necessity for establishing E/M Codes - ANSWER: Place of Service; Type of Service; Patient Status nomenclature - ANSWER: naming system nursing informatics - ANSWER: integrates nursing science with multiple information and analytical sciences to identify define manage and communicate data information knowledge and wisdom and nursing practice Parallel workflow - ANSWER: two or more steps in a process can occur concurrently. Patient Protection and Affordable Care Act (ACA) - ANSWER: Guarantees healthcare for all Americans, expands Medicaid, provides incentives intended to improve care coordination and quality, restructures healthcare payment, and provides additional information to patients so that they can make value- based decisions. patient-centered information systems - ANSWER: patient centered information systems focused on collecting data and disseminating information related to direct care POE/CPOE/CDS - ANSWER: POE- practitioner order entry, CPOE- computerized practitioner order entry, CDS- clinical decision support Primary Goal of CDS Tools - ANSWER: leverage data and the scientific evidence to help guide appropriate decision making. Privacy - ANSWER: Practice of maintaining the security and confidentiality of patient records. privacy - ANSWER: The right to be left alone when you want to be, to have control over your own personal possessions, and not to be observed without your consent Rationale APP is NOT Considered Medical Devices - ANSWER: Apps that are not intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease.