Nurse's Role in Electronic Medical Records (EMR) Quiz
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Questions and Answers

What information in the electronic medical record (EMR) can help a nurse plan and manage a patient's post-operative care after open-heart surgery?

  • MAR
  • Laboratory results over the last 72 hours (correct)
  • Provider orders
  • Nursing flowsheets

    • In addition to nursing flowsheets and provider orders, what information in a patient's electronic medical record (EMR) helps a nurse plan and manage fluctuations in blood glucose levels?

  • Laboratory results over the last 72 hours
  • MAR (correct)
  • Provider orders
  • Nursing flowsheets

    • What list of information in the electronic medical record (EMR) will help a nurse plan the care for a patient admitted to the hospital with COVID-19?

  • Laboratory results over the last 72 hours (correct)
  • Nursing flowsheets
  • Provider orders
  • MAR

    • According to the United States Core Data for Interoperability (USC DI) standards, which clinical note type is exempt from being shared with patients?

    <p>Psychotherapy notes</p> Signup and view all the answers

    What resolution can improve the workflow issue of increased turnaround time between surgical cases blamed on the manual tracking system?

    <p>Radiofrequency identification (RFID) in patient labels</p> Signup and view all the answers

    What is an effective way to reduce the risk of access to electronic protected health information (ePHI) by unauthorized users?

    <p>Regularly updating and strengthening security protocols</p> Signup and view all the answers

    What is the intent of the Clinical Decision Support (CDS) System?

    <p>Providing clinicians with knowledge &amp; person-specific information.</p> Signup and view all the answers

    Where should a nurse find the fluid status of a patient when asked by a physician?

    <p>The intake &amp; output chart</p> Signup and view all the answers

    In a healthcare setting, which method should be used to motivate staff to adopt a new Electronic Health Record (EHR)?

    <p>Involve staff in the implementation process.</p> Signup and view all the answers

    What represents privacy & security risks for telehealth technology?

    <p>Patients have the option to use the speakerphone in the telehealth apps.</p> Signup and view all the answers

    Which government organization oversees the meaningful use program?

    <p>CMS (Centers for Medicare and Medicaid Services)</p> Signup and view all the answers

    What form allows stored information in an Electronic Health Record (EHR) to be instantly searched, retrieved, combined, & reported in different ways?

    <p>Text data</p> Signup and view all the answers

    Which act in 2009 did Meaningful Use (MU) originate?

    <p>'American Recovery and Reinvestment Act' (ARRA)</p> Signup and view all the answers

    'MRSA' requires which type of precautions?

    <p>'Contact precautions'</p> Signup and view all the answers

    '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?'

    <p>'Workflow'</p> Signup and view all the answers

    What is the primary purpose of predictive modeling/analytics?

    <p>To forecast the likelihood of an event occurring</p> Signup and view all the answers

    What is the fundamental principle of non-maleficence and fidelity related to?

    <p>Promoting patient safety</p> Signup and view all the answers

    What does HIPAA stand for and in which year did it form?

    <p>Health Insurance Portability &amp; Accountability Act, 1996</p> Signup and view all the answers

    What is the action taken when two nurses commit HIPAA violations by discussing lab reports in the cafeteria?

    <p>Fines imposed</p> Signup and view all the answers

    During which phase of the systems development life cycle should a system be activated to effectively be used by end users?

    <p>Implementation</p> Signup and view all the answers

    What is the barrier to using biometrics in healthcare?

    <p>Financial limitations</p> Signup and view all the answers

    Where should a nurse find the information to put a homeless man IV drug user in isolation within the EMR?

    <p>Medical history and diagnosis</p> Signup and view all the answers

    What system alerts a nurse when a medication alert pops up?

    <p>Clinical Decision Support (CDS) System</p> Signup and view all the answers

    What graph or chart is used when comparing infection rates across the states?

    <p>Bar graph</p> Signup and view all the answers

    What is the main way to keep HIPAA compliance?

    <p>Passwords</p> Signup and view all the answers

    What represents the goal of Health Information Exchange?

    <p>Facilitating communication between healthcare providers</p> Signup and view all the answers

    What would be the causes to put someone in isolation?

    <p>MRSA, Influenza, TB</p> Signup and view all the answers

    What is included in the concept of meaningful use?

    <p>Adoption of electronic health records (EHR)</p> Signup and view all the answers

    What is the best method of Electronic Medical Record charting for nursing or data Entry fields?

    <p>Checklist-based entry</p> Signup and view all the answers

    When can you get notes from the provider quickly?

    <p>Health Information Exchange</p> Signup and view all the answers

    What element is considered Protected Health Information (PHI)?

    <p>'Date of birth (DOB)'</p> Signup and view all the answers

    Which of the following is a potential disadvantage of template-based charting in electronic health records (EHR)?

    <p>Increased risk of human errors</p> Signup and view all the answers

    What is the primary concern when planning discharge teaching for a patient with diabetes?

    <p>Time of day for teaching</p> Signup and view all the answers

    In the context of informatics, how can a person's health literacy be assessed?

    <p>Evaluating the patient's current understanding</p> Signup and view all the answers

    What type of information representation are pie charts primarily used for?

    <p>Percentages</p> Signup and view all the answers

    When does discharge planning typically begin for patients?

    <p>On admission</p> Signup and view all the answers

    Which solution could potentially address the challenge of overwhelming data-entry fields in electronic health records?

    <p>Cascading documentation</p> Signup and view all the answers

    What must be protected under HIPAA regulations when handling records for insurance purposes?

    <p>Name and birthdate/year</p> Signup and view all the answers

    What should a nurse do upon discovering 100 errors in coding?

    <p>Report the errors to the relevant authorities</p> Signup and view all the answers

    What is the purpose of regression testing in software development?

    <p>To ensure the software still functions as expected after updates or changes</p> Signup and view all the answers

    What is the potential drawback of a high number of data-entry fields in electronic health records?

    <p>Difficulty finding where information should be documented</p> Signup and view all the answers

    Which visual representation can be used to evaluate patient safety, quality performance, and compare services?

    <p>Trending graph</p> Signup and view all the answers

    What graph represents COVID positive results best for statistical analysis?

    <p>Scatterplot</p> Signup and view all the answers

    What is an example of the benefit of using Computerized Provider Order Entry (CPOE) & DSS for a physician?

    <p>Alerts when ordering Viagra (sildenafil) when patient is taking a cardiac med</p> Signup and view all the answers

    Why is it important to control the number of warnings in an Electronic Health Record (EHR)?

    <p>To minimize alert fatigue</p> Signup and view all the answers

    From which act in 2009 did Meaningful Use (MU) originate?

    <p>ARRA act</p> Signup and view all the answers

    Which two technologies support the standardization of healthcare data?

    <p>DICOM &amp; HL7 (Health Level 7)</p> Signup and view all the answers

    What tool should informatics and ER nurses use for a process analysis of a patient admission form?

    <p>SWOT analysis</p> Signup and view all the answers

    Which government agency recommended the use of bar code medication administration?

    <p>FDA (Food and Drug Administration)</p> Signup and view all the answers

    What type of report should nurse informaticists create for a one-time request of patients with blood glucose >400 mg/dL in July, using information stored in the electronic health record?

    <p>&quot;Short-time&quot; report</p> Signup and view all the answers

    What represents an ethical/legal issue with rural hospital & tele-radiology?

    <p>State licensing issue</p> Signup and view all the answers

    What is the benefit of Internet/externet in healthcare settings?

    <p>Enhanced team collaboration</p> Signup and view all the answers

    What role can a nurse informaticist help support & change in the context of EHR challenges?

    <p>Analyzing &amp; redesigning workflows</p> Signup and view all the answers

    What is the primary goal of EHR incentive programs, such as meaningful use?

    <p>To promote the achievement of quality, safety, &amp; efficiency measures</p> Signup and view all the answers

    What can managers do to determine completion of clinical documentation by nurses?

    <p>Randomly run EHR reports &amp; list noncompliant nurses</p> Signup and view all the answers

    Which data set informs the decision to review the protocol for falls on the med-surg unit?

    <p>The radiology reports of pts with a reported fall on the med-surg unit</p> Signup and view all the answers

    What data in a medical record informs the management of the pt's condition following a surgical procedure?

    <p>Nursing assessment from the prior shift &amp; the doctor's orders</p> Signup and view all the answers

    Which data in the pt's medical record would tell a nurse to implement infection control precautions?

    <p>The nursing flow sheet documenting wound status</p> Signup and view all the answers

    What represents 2 barriers that prevent interoperability between health systems?

    <p>Data blocking &amp; interface cost</p> Signup and view all the answers

    'Where can a nurse find the fluid status of a patient when asked by a physician?'

    <p>'In the nursing flow sheet documenting wound status'</p> Signup and view all the answers

    What system alerts a nurse when a medication alert pops up?

    <p>Medication administration records system for the unit</p> Signup and view all the answers

    Which solution could potentially address the challenge of overwhelming data-entry fields in electronic health records?

    <p>Standardizing healthcare data across systems</p> Signup and view all the answers

    What is the dollar amount price range for a HIPAA fine per violation?

    <p>$100-50,000</p> Signup and view all the answers

    What is the Act that recognizes patients' need for more power in their healthcare and emphasizes access to information?

    <p>21st Century Cures Act</p> Signup and view all the answers

    What should a nurse do when a hospital employee falls and their manager calls for an update?

    <p>Provide limited information</p> Signup and view all the answers

    What is the best practice for HIPAA compliance when a patient's employer calls asking for information on a patient who got hurt at work?

    <p>Ask employer to submit a signed agreement to protect the patient info</p> Signup and view all the answers

    What is the recommended action when Clinical Decision Support System (CDSS) is ignored?

    <p>Educate staff on the importance</p> Signup and view all the answers

    What does a focus group primarily do in healthcare settings?

    <p>Gathering uses to discuss</p> Signup and view all the answers

    What is the goal of Health Information Exchange (HIE)?

    <p>To allow insurance companies &amp; providers to share data</p> Signup and view all the answers

    What does a peripheral biometric device primarily do?

    <p>Monitor high blood pressure</p> Signup and view all the answers

    What is the most correct method for electronically capturing patient vital signs without manual entry?

    <p>Biomedical device integration</p> Signup and view all the answers

    What is the primary purpose of predictive modeling/analytics?

    <p>To identify trends and patterns in healthcare data</p> Signup and view all the answers

    What represents the goal of Health Information Exchange (HIE)?

    <p>To improve interoperability and accessibility of patient information across healthcare organizations</p> Signup and view all the answers

    What can managers do to determine completion of clinical documentation by nurses?

    <p>Conduct regular audits and reviews of clinical documentation completion rates</p> Signup and view all the answers

    What element is considered Protected Health Information (PHI)?

    <p>Patient's social security number</p> Signup and view all the answers

    What should a nurse recommend to promote nurse to patient interactions?

    <p>Use technology to enhance communication with patients</p> Signup and view all the answers

    What is an effective way to reduce the risk of access to electronic protected health information (ePHI) by unauthorized users?

    <p>Implementing role-based access controls for ePHI</p> Signup and view all the answers

    What is the barrier to using biometrics in healthcare?

    <p>Concerns about the accuracy and privacy of biometric data</p> Signup and view all the answers

    Which visual representation can be used to evaluate patient safety, quality performance, and compare services?

    <p>Bar graph</p> Signup and view all the answers

    What is the potential drawback of a high number of data-entry fields in electronic health records?

    <p>Overwhelming healthcare providers with excessive documentation requirements</p> Signup and view all the answers

    Study Notes

    Electronic Medical Records (EMR) and Post-Operative Care

    • EMR provides essential data regarding patient history, medications, allergies, and surgical notes for effective post-operative planning.
    • Nursing flowsheets track vital signs and assessments critical for monitoring recovery.
    • Provider orders detail pain management protocols and medications tailored for post-operative recovery.

    Monitoring Blood Glucose Levels

    • Historical blood glucose data in EMRs aids in identifying patterns and managing fluctuations.
    • Lab results, nutrition assessments, and medication records provide insights into diabetes management.

    Planning Care for COVID-19 Patients

    • EMRs contain vital information on symptoms, test results, treatment plans, and vaccination status.
    • Previous medical history, such as comorbidities and prior hospitalizations, is crucial for tailored care.

    US Core Data for Interoperability (USCDI) Standards

    • The exempt clinical note type is the psychotherapy note, which is not shared with patients under HIPAA regulations.

    Workflow Improvements in Surgical Cases

    • Implementing automated tracking systems enhances the efficiency of surgical case turnovers, reducing manual error.

    Protecting Electronic Protected Health Information (ePHI)

    • Multi-factor authentication and regular training on data handling are critical strategies to prevent unauthorized access to ePHI.

    Clinical Decision Support (CDS) System Intent

    • CDS systems aim to enhance decision-making by providing alerts, reminders, and relevant patient information at the point of care.

    Accessing Fluid Status in EMR

    • Fluid status is typically found in the patient's vital signs section or nursing assessments within the EMR.

    Motivating Staff to Adopt EHR

    • Engaging staff through training sessions and demonstrating the benefits of EHR can facilitate smoother adoption and reduce resistance.

    Risks with Telehealth Technology

    • Privacy and security issues arise from potential unauthorized access to patient information during virtual consultations.

    Oversight of Meaningful Use Program

    • The Centers for Medicare & Medicaid Services (CMS) regulate and promote the meaningful use program.

    Structured Information Retrieval in EMR

    • Data models like C-CDA (Consolidated Clinical Document Architecture) enable instant searching, retrieval, and reporting of health records.

    Origin of Meaningful Use (MU)

    • The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 initiated the concept of meaningful use.

    Infection Precautions for MRSA

    • Contact precautions are necessary for managing patients with Methicillin-resistant Staphylococcus aureus (MRSA).

    Task Guidance in EHR

    • Task lists or reminders in the EHR delineate the required nursing actions for each shift.

    Predictive Modeling/Analytics Purpose

    • The primary goal is to anticipate patient outcomes and inform clinical decisions, enhancing preventive care.

    Non-maleficence and Fidelity Principles

    • These ethical principles focus on avoiding harm to patients and maintaining trust within the nurse-patient relationship.

    HIPAA Overview

    • HIPAA stands for the Health Insurance Portability and Accountability Act, established in 1996 to protect patient privacy.

    Resolving HIPAA Violations

    • Reporting the breach to higher authorities and reviewing protocols are necessary actions when HIPAA violations occur.

    Systems Development Life Cycle

    • The system should be activated during the implementation phase for effective usage by end users.

    Barriers to Biometric Usage in Healthcare

    • Privacy concerns and high implementation costs limit the widespread adoption of biometrics.

    EMR Isolation Information

    • Isolation protocols can typically be accessed in the patient's clinical notes and infection control section of the EMR.

    Medication Alert Systems

    • Computerized provider order entry (CPOE) systems trigger alerts for potential medication errors or contraindications.

    Comparing Infection Rates

    • Control charts and statistical graphs help visualize and compare infection rates across states for epidemiological studies.

    Maintaining HIPAA Compliance

    • Regular employee training, secure data access, and proper handling of PHI are essential for compliance.

    Health Information Exchange (HIE) Goal

    • HIE aims to facilitate the sharing of health information necessary for coordinated patient care.

    Causes for Patient Isolation

    • Infectious diseases, exposure to contagious pathogens, and specific symptoms warrant patient isolation.

    Concept of Meaningful Use

    • Includes improving quality of care, enhancing patient engagement, and promoting the interoperability of health data.

    Method for EMR Charting

    • Customized templates in EHR systems enhance efficiency and structured data entry for nursing workflows.

    Quick Access to Provider Notes

    • Accessing the provider's notes through an EMR's documentation section allows for timely reviews of patient history.

    Understanding Protected Health Information (PHI)

    • Elements of health data linked to an individual, including name, medical history, and billing information, qualify as PHI.

    Template-based EHR Charting Disadvantages

    • Template-based charting may hinder individualized patient assessments, leading to potential oversights.

    Discharge Teaching for Diabetic Patients

    • Focus on dietary management, medication adherence, and monitoring techniques are essential for effective discharge teaching.

    Assessing Health Literacy

    • Evaluating patient comprehension through surveys and educational assessments can identify health literacy levels.

    Use of Pie Charts

    • Primarily for displaying categorical data percentages in an easily interpretable format.

    Discharge Planning Timeline

    • Initiation of discharge planning typically occurs at the point of admission to ensure continuity of care.

    Addressing Data Entry Challenges

    • Implementing user-friendly interfaces and streamlining data entry processes can alleviate data entry overload.

    HIPAA Protections for Insurance Records

    • Patient consent is necessary for disclosing records related to insurance claims, safeguarding their privacy.

    Responding to Coding Errors

    • Immediate reporting to compliance officers and conducting audits assists in rectifying coding inaccuracies.

    Purpose of Regression Testing

    • To ensure that software changes do not negatively impact existing functionalities prior to deployment.

    Negative Impact of Data Entry Fields

    • An excessive volume of fields can lead to user fatigue and increased chances of errors in the EHR system.

    Visual Representation for Patient Safety Metrics

    • Dashboards and scorecards effectively present clinical quality performance metrics and safety outcomes.

    COVID-19 Statistical Analysis

    • Line graphs are commonly used to depict trends and comparisons in COVID-19 positive test results over time.

    CPOE and DSS Benefits

    • Improved prescription accuracy and reduced adverse drug events enhance patient safety and care quality through these systems.

    Controlling EHR Warnings

    • Balancing alerts prevents alert fatigue, maintaining clinician attention on critical patient safety notifications.

    Support for Standardizing Healthcare Data

    • HL7 (Health Level Seven) and SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms) are key technologies.

    Process Analysis for Patient Admission

    • Lean methodologies and workflow mapping tools aid in analyzing and optimizing patient admission processes.

    Bar Code Medication Administration Oversight

    • The Food and Drug Administration (FDA) promotes the adoption of bar code medication administration for improved safety.

    Specific Data Report Generation

    • Custom charts or queries can extract relevant patient data above specified blood glucose thresholds from EHRs.

    Ethical Issues with Tele-Radiology

    • Concerns about the quality of care and timely interpretations of radiological evidence pose legal challenges in rural settings.

    Internet/Extranet Benefits

    • Increased access to patient information and collaboration among healthcare providers enhances the quality of care delivery.

    Support Role of Nurse Informaticists

    • Nurse informaticists facilitate training, provide solutions for EHR challenges, and advocate for user-friendly interfaces.

    EHR Incentive Program Goals

    • Aims to enhance healthcare quality, safety, and efficiency while promoting the meaningful use of health information technology.

    Monitoring Clinical Documentation Completion

    • Managers can utilize audit tools and quality improvement metrics to ensure documentation compliance by nursing staff.

    Data Reviews to Prevent Falls

    • Analyzing incident reports and nursing assessments helps inform fall prevention protocols in clinical settings.

    Post-Surgical Data for Condition Management

    • Relevant information includes vitals, surgical notes, and progress summaries for evaluating recovery post-surgery.

    Infection Control Precautions Trigger

    • Elevated laboratory values, clinical symptoms, or confirmed infections prompt implementation of infection control measures.

    Interoperability Barriers

    • Differing data standards and reliance on legacy systems hinder seamless information exchange among health entities.

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    Description

    Test your knowledge on the information in an electronic medical record (EMR) that helps a nurse plan and manage post-operative care, fluctuations in blood glucose levels, and care for patients admitted with COVID-19.

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