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In conducting & providing a quality audit, it was noted the provider was free texting data instead of selecting the proper codes to capture & bill for their services. When educating this provider on properly selecting codes & decreasing free texting what is a rationale for why this is i...

In conducting & providing a quality audit, it was noted the provider was free texting data instead of selecting the proper codes to capture & bill for their services. When educating this provider on properly selecting codes & decreasing free texting what is a rationale for why this is important? Interoperability. The use of standardized data sets is critical for EHR. Which 2 standards support the interoperability of healthcare data? DICOM standards. HL7 standards. What is a typical role of an informatics nurse? Facilitates the development, implementation, & integration for laboratory information systems. What is the responsibility of a superuser? To support the system in a given unit & assist users with functionality & procedural issues. A nursing clinical analyst is being interviewed by a nursing student who is requesting a detailed explanation of the role of a nursing informaticist. Which nursing informaticist goals would this clinical analyst offer in response? The goals facilitate an environment where technology, information, & understanding directs nurses’ judgment . What is the role of the informatics nurse working with EHR? To improve patient safety. What is a reason to have standardized terminology within a healthcare setting? It provides the effective exchange of information between providers. What is the harmonization of terminologies? It fosters interoperability in health information systems. Which item describes a basic network code that determines the rules used to create & route packet of data between network devices? Transmission control protocol/internet protocol (TCP/IP). What can be installed to allow a device to connect to the EHR to enable the exchange of data? An application program interface. How does the health information exchange (HIE) improve interoperability within a healthcare organization? It allows patient information to be accessible despite where the patient is receiving care. What are connectivity systems? They support the integration of data across different organizations. The healthcare organization has a different surgery system that is integrated with the organization’s main EHR. What should this healthcare team do to ensure all information is properly charted? Chart in the surgical system & the appropriate data will be accessible in the HER. 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? Master patient index. Health systems can be inoperable with other health systems. What are 2 barrier that prevent interoperability? Data blocking. Interface cost. What is considered to be clinical decision support (CDS) within the EHR? The condition or disease-specific order sets. Unit managers want to be assured nurses are signing completed clinical documentation. What can managers do to determine documentation completion? Randomly run EHR reports & list noncompliant nurses. Which area of the EHR is used to guide a nurse on the tasks that need to be completed during the shift? The worklist. When a physician arrived in the unit, a nurse was asked about the fluid status of a patient. Where should this nurse find this information? The intake & output section. On admission, a patient reports several allergies. Where does the nurse confirm the documentation of this information? In the patient summary tab. 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? Scan the patient’s armband & the medication. What is the primary purpose of a clinical decision support system (CDSS)? It provides clinicians with suggested care information. How is clinical decision support system (CDSS) represented in an EHR? Through alerts & reminders. In a healthcare setting, there is resistance towards using a new EHR. The staff insists the prior system was much faster than navigating this new EHR. Which method should be used to motivate staff to adopt this EHR? Involve staff in the implementation process. Which tool highlights the areas in which information technology can improve efficiency & support an interdisciplinary healthcare team? A workflow analysis. Which statement defines electronic protected health information (ePHI)? It is information used to specifically identify an individual. An informatics nurse is developing a web-based application for patient care. Which statement accurately describes the internet? An unregulated network of networks. What is role-based access an example of? Authenticity. Which term refers to ensuring confidentiality when sharing a patient’s electronic personal health information? Security. What advice should be taken to avoid a security breach of protected health information? Open emails only from trusted sources, change passwords as stipulated by the organization, and do no leave ePHI visible in an unsecure area.

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