Chapter 10: Information Technology for Safe and Quality Patient Care

MULTIPLE CHOICE

1. A patient is changing health-care providers and wants to take his medical record with him. He has a significant medical history with several comorbidities and frequent hospitalizations at several hospitals in his geographical area. What would the patient do based on this circumstance?

1. Access his electronic medical record (EMR) and print out copies to take with him when he has his initial meeting with his new health-care provider.

2. Provide information from his personal health record (PHR).

3. Attempt to directly access his electronic health record (EHR) to obtain information.

4. Gather information from his EMR that will provide information about all of his hospitalizations in different health-care settings as it provides a comprehensive overview of his medical history.

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2. The nurse is admitting a patient who has community-acquired pneumonia (CAP). While documenting the patient’s history in the medical record, the nurse encounters prompts for further information relative to the medical diagnosis. What is this an example of?

1. Data mining

2. Standardization of language

3. Alert

4. Activation of a rule

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3. In order to establish “meaningful use” with regard to providing health-care services, what would the nurse expect that the physician must do?

1. Sign all electronic health-care records for their respective patients.

2. Document that improved health outcomes are met while reducing overall fees and reimbursement.

3. Complete all required elements defined by the Centers for Medicare and Medicaid Services (CMS).

4. Reduce patient fees for services provided in order to increase access to medical care for patients.

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4. A nurse is assisting a patient with reviewing an explanation of benefits (EOB) in relationship to insurance reimbursement. The patient has a history of Diabetes, Type 1 and went to the physician for an office visit. To determine which code reflects the office visit, what would the nurse examine?

1. Discrete data

2. ICD (International Classification of Diseases)

3. CPT (Current Procedural Terminology)

4. Data sets

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5. The nurse has just come on shift after receiving initial report and one of the patients is requesting pain medication. In order for a nurse to administer this medication to a patient using the electronic medication administration record (eMAR), which application must be in place?

1. Completion of full shift nursing assessment in patient’s medical record

2. Computerized provider order entry (CPOE) noted in chart for pain medication

3. Using one patient identifier for confirmation

4. Access to the patient portal

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6. A nurse working on a medical-surgical unit is trying to integrate services of the informatics department to help improve patient outcomes. Which person would the nurse contact in order to develop an understanding of how the computer system would work?

1. Network engineer

2. Clinical analyst

3. Clinical systems educator

4. Chief nursing information officer

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7. Who is a key stakeholder that is a critical part of the informatics team when attempting to implement an electronic documentation system?

1. Physician or health-care provider

2. A superuser who is an expert

3. A superuser who is a shift expert

4. IT support

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MULTIPLE RESPONSE

8. In order to achieve a well-functioning information system within a health-care setting, which element should be included? Select all that apply.

1. Information is stored at the individual level.

2. Information is stored at the organizational level.

3. Specific specialty designed systems allow for better integration of services.

4. Customization of systems can only be achieved when using a home-grown system.

5. Financial systems are included in administrative systems.

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9. Health-care legislation in the United States focuses on the ability of health-care providers in their delivery of care to patients to meet which type of standards? Select all that apply.

1. Using encryption methods to prevent data breaches

2. Improving outcomes related to patient care

3. Assessing penalties and/or reducing paid benefits if standards are not met

4. Maintaining adherence to state level–initiated Health Insurance Portability and Accountability Act (HIPAA)

5. Standards established at the community level

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10. Which methods would help to support nursing documentation and communication during downtime in the clinical setting when using an electronic documentation system? Select all that apply.

1. Have a plan in place for planned downtime.

2. Make sure that staff is made aware of the planned downtime schedule.

3. Tape record all nursing notes and then have them transcribed once the system is restored.

4. Ensure that all stakeholders play a role in the creation and implementation of communication and documentation channels before initiation of electronic charting.

5. Make sure that the nurse has backed up the files to a personal flash drive.

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