Chapter 14
Question 1
A hospital client sees the nurse documenting information into the computer. She asks the
nurse why the computer is better than the "old patient chart like hospitals have always used."
Which of the following points would be accurate to say about an electronic medical record?
1. It captures the information needed for billing purposes.
2. It is more secure than a paper record.
3. More than one person can access the record at any given time.
4. The record is available when and where needed.
5. Data are in real-time, as things happen.
Correct Answer: 1,2,3,4,5
Rationale 1:
The nurse could also say that the traditional paper medical record no longer meets the needs
of today's health care industry.
Rationale 2:
The nurse could also say that the traditional paper medical record no longer meets the needs
of today's health care industry.
Rationale 3:
The nurse could also say that the traditional paper medical record no longer meets the needs
of today's health care industry.
Rationale 4:
The nurse could also say that the traditional paper medical record no longer meets the needs
of today's health care industry.
Rationale 5:
The nurse could also say that the traditional paper medical record no longer meets the needs
of today's health care industry.
Question 2
Which of the following topics must be addressed when giving a presentation to physicians on
the benefits of the electronic medical record (EMR)?
1. Easier access to previous documented encounters
2. Facilitation of clinical pathways
3. Chart access speed
4. Trends and graphics are not available on demand
5. Reduced liabilities through accurate documentation
Correct Answer: 1,2,3,5
Rationale 1:
II. Facilitates critical and clinical pathways.
III. Chart access is faster.
IV. Trends and clinical graphics are available on demand.
V. Liabilities can be reduced through better documentation.
VI. Prompts are provided to ensure administration and documentation of medications and
treatments.
Rationale 2:
II. Facilitates critical and clinical pathways.
III. Chart access is faster.
IV. Trends and clinical graphics are available on demand.
V. Liabilities can be reduced through better documentation.
VI. Prompts are provided to ensure administration and documentation of medications and
treatments.
Rationale 3:
II. Facilitates critical and clinical pathways.
III. Chart access is faster.
IV. Trends and clinical graphics are available on demand.
V. Liabilities can be reduced through better documentation.
VI. Prompts are provided to ensure administration and
documentation of medications and treatment.
Rationale 4:
II. Facilitates critical and clinical pathways.
III. Chart access is faster.
IV. Trends and clinical graphics are available on demand.
V. Liabilities can be reduced through better documentation.
VI. Prompts are provided to ensure administration and documentation of medications and
treatments.
Rationale 5:
II. Facilitates critical and clinical pathways.
III. Chart access is faster.
IV. Trends and clinical graphics are available on demand.
V. Liabilities can be reduced through better documentation.
VI. Prompts are provided to ensure administration and documentation of medications and
treatments.
Question 3
While most hospitals have some level of automation, few have attained a fully electronic
environment. Health care Information and Management Systems Society (HIMSS) analytics
created an EMR adoption model that identifies eight levels of EMR capabilities. Your
hospital has been designated as a Stage 3 facility. Which of the following is accurate about an
organization at Stage 3 level?
1. Computerized provider order entry (CPOE) and better EBP clinical decision support is
available.
2. Some clinical automation exists.
3. Basic clinical documentation is required.
4. Major ancillary clinical systems are all installed (laboratory, pharmacy, and radiology
systems).
Correct Answer: 3
Rationale 1:
Basic clinical documentation is required for Stage 3. The stages of the model range from
minimal automation at stage 0 to full automation at stage 7. Each subsequent stage presumes
the existence of the functionalities listed for the preceding stage. Your choice "Computerized
provider order entry (CPOE) and better EBP clinical decision support" matches Stage 4.
Rationale 2:
Basic clinical documentation is required for Stage 3. The stages of the model range from
minimal automation at stage 0 to full automation at stage 7. Each subsequent stage presumes
the existence of the functionalities listed for the preceding stage. Your choice "Some clinical
automation exists" matches Stage 0.
Rationale 3:
Basic clinical documentation is indeed required for Stage 3. The stages of the model range
from minimal automation at stage 0 to full automation at stage 7. Each subsequent stage
presumes the existence of the functionalities listed for the preceding stage.
Rationale 4:
Basic clinical documentation is required for Stage 3. The stages of the model range from
minimal automation at stage 0 to full automation at stage 7. Each subsequent stage presumes
the existence of the functionalities listed for the preceding stage. Your choice "Major
ancillary clinical systems are all installed" matches a Stage 2.
Question 4
The U.S. Department of Health and Human Services indicated that the ________________ is
a digital collection of patient's medical history.
Correct Answer: EHR (Electronic Health Record)
Rationale:
The U.S. Department of Health and Human Services indicated that the Electronic Health
Record is a digital collection of patient's medical history. Items included are:
1. diagnosed medical conditions
2. prescribed medications
3. vital signs
4. immunizations
5. lab results
6. personal characteristics such as age and weight
Question 5
Information in the electronic health record (EHR) may be owned by the patient or
stakeholder. Which of the following about the EHR is different than the electronic medical
record (EMR)?
1. It does not provide interactive client access.
2. Clients may append information if desired.
3. Dental records components are not included.
4. The EHR records and manages only episodic information.
Correct Answer: 2
Rationale 1:
Unlike the EMR, the EHR provides the ability for the client to append information; it does
provide interactive client access.
Rationale 2:
Unlike the EMR, the EHR provides the ability for the client to append information; it
provides interactive client access.
Rationale 3:
Unlike the EMR, the EHR provides the ability for the client to append information; it
provides interactive client access. The Department of Defense has added dental records to the
list of EHR components.
Rationale 4:
Unlike the EMR, the EHR provides the ability for the client to append information. It does
record and manage longitudinal EHR information as well as episodic data.
Question 6
For many years the EMR applied to a single encounter with no ability, or very limited ability,
to carry information from one visit to another within a care delivery system. That situation
has changed; it is now possible to bring information forward from prior visits within the
organization or delivery system. Which of the following answers are basic components of the
EMR system?
1. Clinical messaging and e-mail
2. Results reporting
3. Decision support
4. Clinical documentation
5. Order entry
Correct Answer: 1,2,3,4,5
Rationale 1:
The following are the basic components of the EMR system:
1. Clinical messaging and e-mail
2. Results reporting
3. Data repository
4. Decision support
5. Clinical documentation
6. Order entry
Rationale 2:
The following are the basic components of the EMR system:
1. Clinical messaging and e-mail
2. Results reporting
3. Data repository
4. Decision support
5. Clinical documentation
6. Order entry
Rationale 3:
The following are the basic components of the EMR system:
1. Clinical messaging and e-mail
2. Results reporting
3. Data repository
4. Decision support
5. Clinical documentation
6. Order entry
Rationale 4:
The following are the basic components of the EMR system:
1. Clinical messaging and e-mail
2. Results reporting
3. Data repository
4. Decision support
5. Clinical documentation
6. Order entry
Rationale 5:
The following are the basic components of the EMR system:
1. Clinical messaging and e-mail
2. Results reporting
3. Data repository
4. Decision support
5. Clinical documentation
6. Order entry
Question 7
Which of the following is a major component of the computer-based patient record (CPR)?
1. Results reporting including unstructured data reports
2. Legal record created in hospitals and ambulatory environments
3. Support for links to local or remote information resources
4. Integration of all pertinent patient information into one record
Correct Answer: 3
Rationale 1:
A major component of the CPR is support for links to local or remote information resources.
Results reporting including unstructured data reports are part of the EMR.
Rationale 2:
A major component of the CPR is support for links to local or remote information resources.
The EMR is a legal record created in hospitals and ambulatory environments.
Rationale 3:
A major component of the CPR is support for links to local or remote information resources.
Rationale 4:
A major component of the CPR is support for links to local or remote information resources.
The EHR integrates all pertinent patient information into one record.
Question 8
The Bush administration called for the adoption of the electronic health record (EHR) by
2014 as a means to help transform U.S. health care. Who owns the individual client record
when an EHR is used?
1. The client
2. Ownership is unclear
3. The institution at which the record is created
4. The health care providers who enter the data
Correct Answer: 2
Rationale 1:
Ownership is unclear for the individual client record when an EHR is used. This is a complex
question. With the development of the EHR, ownership issues become more complex.
Because many providers use the same data, it is unclear who actually owns the record and
who is responsible for maintaining accuracy. Because the data are shared and updated from
many sites, decisions must be made regarding who can access the data and how they will be
used. In addition, it must be determined where the EHR data will actually be stored.
Rationale 2:
Ownership is unclear for the individual client record when an EHR is used. This is a complex
question. With the development of the EHR, ownership issues become more complex.
Because many providers use the same data, it is unclear who actually owns the record and
who is responsible for maintaining accuracy. Because the data are shared and updated from
many sites, decisions must be made regarding who can access the data and how they will be
used. In addition, it must be determined where the EHR data will actually be stored.
Rationale 3:
Ownership is unclear for the individual client record when an EHR is used. This is a complex
question. With the development of the EHR, ownership issues become more complex.
Because many providers use the same data, it is unclear who actually owns the record and
who is responsible for maintaining accuracy. Because the data are shared and updated from
many sites, decisions must be made regarding who can access the data and how they will be
used. In addition, it must be determined where the EHR data will actually be stored.
Rationale 4:
Ownership is unclear for the individual client record when an EHR is used. This is a complex
question. With the development of the EHR, ownership issues become more complex.
Because many providers use the same data, it is unclear who actually owns the record and
who is responsible for maintaining accuracy. Because the data are shared and updated from
many sites, decisions must be made regarding who can access the data and how they will be
used. In addition, it must be determined where the EHR data will actually be stored.
Question 9
Which of the following are major impediments to the development of an electronic health
record (EHR)?
1. Development of an electronic infrastructure
2. Confidentiality
3. Cost
4. Lack of a common vocabulary
5. Information system vendors
Correct Answer: 1,2,3,4
Rationale 1:
Major impediments to the development of an EHR are cost, lack of a common vocabulary,
infrastructure, and confidentiality. Others are security, resistance among caregivers, and a
lack of IT staff.
Rationale 2:
Major impediments to the development of an EHR are cost, lack of a common vocabulary,
infrastructure, and confidentiality. Others are security, resistance among caregivers, and a
lack of IT staff.
Rationale 3:
Major impediments to the development of an EHR are cost, lack of a common vocabulary,
infrastructure, and confidentiality. Others are security, resistance among caregivers, and a
lack of IT staff.
Rationale 4:
Major impediments to the development of an EHR are cost, lack of a common vocabulary,
infrastructure, and confidentiality. Others are security, resistance among caregivers, and a
lack of IT staff.
Rationale 5:
Major impediments to the development of an EHR are cost, lack of a common vocabulary,
infrastructure, and confidentiality. Others are security, resistance among caregivers, and a
lack of IT staff. Information system vendors are not an impediment.
Question 10
Which of the following statements is true about the benefits of the electronic health record
(EHR)?
1. It improves the quality of health care.
2. Health care executives have developed strong organizational structures around the EHR.
3. The EHR fosters continuity of health care.
4. Little scientific evidence now exists on what benefits are actually delivered.
Correct Answer: 4
Rationale 1:
Little scientific evidence now exists on benefits actually delivered, despite the many cited
benefits associated with the EHR. This lack of evidence hinders evaluation of the costs,
benefits, and risks of a commercial EMR purchase, and makes it difficult for health care
executives to make necessary organizational changes. It is the PHR is that fosters improved
overall quality of health care.
Rationale 2:
Little scientific evidence now exists on benefits actually delivered, despite the many cited
benefits associated with the EHR. This lack of evidence hinders evaluation of the costs,
benefits, and risks of a commercial EMR purchase, and makes it difficult for health care
executives to make necessary organizational changes. Health care executives have not
developed strong organizational structures.
Rationale 3:
Little scientific evidence now exists on benefits actually delivered, despite the many cited
benefits associated with the EHR. This lack of evidence hinders evaluation of the costs,
benefits, and risks of a commercial EMR purchase, and makes it difficult for health care
executives to make necessary organizational changes. It is the PHR is that fosters continuity
of care.
Rationale 4:
Little scientific evidence now exists on benefits actually delivered, despite the many cited
benefits associated with the EHR. This lack of evidence hinders evaluation of the costs,
benefits, and risks of a commercial EMR purchase, and makes it difficult for health care
executives to make necessary organizational changes.
Question 11
Healthcare Information and Management Systems Society (HIMSS) has defined and
described the term electronic Personal Health Record (ePHR). Which of the following are
included in the HIMSS definition and description?
1. Universally accessible
2. Owned and managed by the individual (or legal proxy)
3. Usually considered a legal record
4. Common data set of electronic health information
5. Lifelong tool for managing relevant health information
Correct Answer: 1,2,4,5
Rationale 1:
The HIMSS definition of an ePHR includes: it is a lifelong tool for managing relevant health
information, is universally accessible, is owned and managed by the individual (or legal
proxy(s)), and is a common data set of electronic health information, and universally
accessible. The ePHR must be kept secure to protect the privacy and confidentiality of the
health information it contains. It is not considered a legal record, unless so defined.
Rationale 2:
The HIMSS definition of an ePHR includes: it is a lifelong tool for managing relevant health
information, is universally accessible, is owned and managed by the individual (or legal
proxy(s)), and is a common data set of electronic health information, and universally
accessible. The ePHR must be kept secure to protect the privacy and confidentiality of the
health information it contains. It is not considered a legal record, unless so defined.
Rationale 3:
The HIMSS definition of an ePHR includes: it is a lifelong tool for managing relevant health
information, is universally accessible, is owned and managed by the individual (or legal
proxy(s)), and is a common data set of electronic health information, and universally
accessible. The ePHR must be kept secure to protect the privacy and confidentiality of the
health information it contains. It is not considered a legal record, unless so defined.
Rationale 4:
The HIMSS definition of an ePHR includes: it is a lifelong tool for managing relevant health
information, is universally accessible, is owned and managed by the individual (or legal
proxy(s)), and is a common data set of electronic health information, and universally
accessible. The ePHR must be kept secure to protect the privacy and confidentiality of the
health information it contains. It is not considered a legal record, unless so defined.
Rationale 5:
The HIMSS definition of an ePHR includes: it is a lifelong tool for managing relevant health
information, is universally accessible, is owned and managed by the individual (or legal
proxy(s)), and is a common data set of electronic health information, and universally
accessible. The ePHR must be kept secure to protect the privacy and confidentiality of the
health information it contains. It is not considered a legal record, unless so defined.
Question 12
Consumers are the primary source of information about their health history and medications.
The patient-carried record (PCR) addresses this. Which of the following are potential
problems associated with the PCR?
1. Loss of the record
2. Legibility
3. Portability
4. Privacy
5. Liability
Correct Answer: 1,2,4,5
Rationale 1:
Potential problems with the PCR include legibility, liability, privacy, and loss of the record
itself. Confidentiality is an additional problem. The fact that the PCR is portable is actually a
benefit; the PCR is also cost-effective. However, some clients can provide an accurate
account while others cannot.
Rationale 2:
Potential problems with the PCR include legibility, liability, privacy, and loss of the record
itself. Confidentiality is an additional problem. The fact that the PCR is portable is actually a
benefit; the PCR is also cost-effective. However, some clients can provide an accurate
account while others cannot.
Rationale 3:
The fact that the PCR is portable is actually a benefit; the PCR is also cost-effective. Potential
problems with the PCR include legibility, liability, privacy, and loss of the record itself.
Confidentiality is an additional problem. However, some clients can provide an accurate
account while others cannot.
Rationale 4:
Potential problems with the PCR include legibility, liability, privacy, and loss of the record
itself. Confidentiality is an additional problem. The fact that the PCR is portable is actually a
benefit; the PCR is also cost-effective. However, some clients can provide an accurate
account while others cannot.
Rationale 5:
Potential problems with the PCR include legibility, liability, privacy, and loss of the record
itself. Confidentiality is an additional problem. The fact that the PCR is portable is actually a
benefit; the PCR is also cost-effective. However, some clients can provide an accurate
account while others cannot.
Question 13
Unlike other health records the _____________________is patient-centered, presenting a
more-balanced view of an individual's health history.
Correct Answer: personal health record
Rationale:
Unlike other health records the PHR is patient-centered, presenting a more-balanced view of
an individual's health history. The portability of information helps consumers to manage their
own health. There are a number of additional consumer PHR benefits.
Question 14
The computer-based patient record (CPR) is a comprehensive lifetime record that includes all
information from all specialties. The Institute of Medicine (IOM) identified major
components of the CPR that are considered to be the "gold standard" attributes. Which of the
following are CPR components?
1. Lack of confidentiality
2. Direct entry for physicians will be available
3. Tools cannot measure cost
4. Provides sporadic access to data
5. Provides a patient problem list
Correct Answer: 5
Rationale 1:
The following are the IOM's CPR components:
-Provides a problem list that indicates the client's current clinical problems for each encounter
-Evaluates and records health status and functional levels using accepted measures
-Documents the clinical reasoning/rationale for diagnoses and conclusions
-Provides a longitudinal or lifetime client record by linking all of the client's data from
previous encounters
-Supports confidentiality, privacy, and audit trails
-Provides continuous access to authorized users
-Allows simultaneous and customized views of the client data for individuals, departments, or
enterprises
-Supports links to local or remote information resources, such as various databases using the
Internet or organization-based intranet resources
-Facilitates clinical problem solving by providing decision analysis tools
-Supports direct entry of client data by physicians
-Includes mechanisms for measuring the cost and quality of care
-Supports existing and evolving clinical needs by being flexible and expandable
Rationale 2:
The following are the IOM's CPR components:
-Provides a problem list that indicates the client's current clinical problems for each encounter
-Evaluates and records health status and functional levels using accepted measures
-Documents the clinical reasoning/rationale for diagnoses and conclusions
-Provides a longitudinal or lifetime client record by linking all of the client's data from
previous encounters
-Supports confidentiality, privacy, and audit trails
-Provides continuous access to authorized users
-Allows simultaneous and customized views of the client data for individuals, departments, or
enterprises
-Supports links to local or remote information resources, such as various databases using the
Internet or organization-based intranet resources
-Facilitates clinical problem solving by providing decision analysis tools
-Supports direct entry of client data by physicians
-Includes mechanisms for measuring the cost and quality of care
-Supports existing and evolving clinical needs by being flexible and expandable
Rationale 3:
The following are the IOM's CPR components:
-Provides a problem list that indicates the client's current clinical problems for each encounter
-Evaluates and records health status and functional levels using accepted measures
-Documents the clinical reasoning/rationale for diagnoses and conclusions
-Provides a longitudinal or lifetime client record by linking all of the client's data from
previous encounters
-Supports confidentiality, privacy, and audit trails
-Provides continuous access to authorized users
-Allows simultaneous and customized views of the client data for individuals, departments, or
enterprises
-Supports links to local or remote information resources, such as various databases using the
Internet or organization-based intranet resources
-Facilitates clinical problem solving by providing decision analysis tools
-Supports direct entry of client data by physicians
-Includes mechanisms for measuring the cost and quality of care
-Supports existing and evolving clinical needs by being flexible and expandable
Rationale 4:
The following are the IOM's CPR components:
-Provides a problem list that indicates the client's current clinical problems for each encounter
-Evaluates and records health status and functional levels using accepted measures
-Documents the clinical reasoning/rationale for diagnoses and conclusions
-Provides a longitudinal or lifetime client record by linking all of the client's data from
previous encounters
-Supports confidentiality, privacy, and audit trails
-Provides continuous access to authorized users
-Allows simultaneous and customized views of the client data for individuals, departments, or
enterprises
-Supports links to local or remote information resources, such as various databases using the
Internet or organization-based intranet resources
-Facilitates clinical problem solving by providing decision analysis tools
-Supports direct entry of client data by physicians
-Includes mechanisms for measuring the cost and quality of care
-Supports existing and evolving clinical needs by being flexible and expandable
Rationale 5:
The following are the IOM's CPR components:
-Provides a problem list that indicates the client's current clinical problems for each encounter
-Evaluates and records health status and functional levels using accepted measures
-Documents the clinical reasoning/rationale for diagnoses and conclusions
-Provides a longitudinal or lifetime client record by linking all of the client's data from
previous encounters
-Supports confidentiality, privacy, and audit trails
-Provides continuous access to authorized users
-Allows simultaneous and customized views of the client data for individuals, departments, or
enterprises
-Supports links to local or remote information resources, such as various databases using the
Internet or organization-based intranet resources
-Facilitates clinical problem solving by providing decision analysis tools
-Supports direct entry of client data by physicians
-Includes mechanisms for measuring the cost and quality of care
-Supports existing and evolving clinical needs by being flexible and expandable
Question 15
An emerging technology related to electronic health record (EHR) progress is the use of the
personal health record (PHR). PHRs store client information that will eventually contribute to
the development of a comprehensive, longitudinal record. Which of the following are found
in a PHR but not found in the EHR?
1. Periodic risk assessment survey results
2. Herbal supplements
3. Legal documentation created in a hospital
4. Decision support
5. Health status parameters such as exercise
Correct Answer: 1,2,4,5
Rationale 1:
The following are found in a PHR but not found in the EHR: periodic risk assessment survey
results, health status parameters such as exercise, decision support, and herbal supplements.
Legal documentation created in a hospital is found in the EHR.
Rationale 2:
The following are found in a PHR but not found in the EHR: periodic risk assessment survey
results, health status parameters such as exercise, decision support, and herbal supplements.
Legal documentation created in a hospital is found in the EHR.
Rationale 3:
Legal documentation created in a hospital is found in the EHR. The following are found in a
PHR but not found in the EHR: periodic risk assessment survey results, health status
parameters such as exercise, decision support, and herbal supplements.
Rationale 4:
The following are found in a PHR but not found in the EHR: periodic risk assessment survey
results; health status parameters such as exercise; decision support; herbal supplements. Legal
documentation created in a hospital is found in the EHR.
Rationale 5:
The following are found in a PHR but not found in the EHR: periodic risk assessment survey
results, health status parameters such as exercise, decision support, and herbal supplements.
Legal documentation created in a hospital is found in the EHR.
Question 16
Which of the following are found with the electronic health record (EHR) but are not found
with the computer-based patient record (CPR)?
1. Evidence-based decision support
2. Assists with the work of planning and delivering evidence-based care
3. Quality management
4. Public health disease surveillance and reporting
5. Comprehensive lifetime record that includes all information from all specialties
Correct Answer: 1,2,3,4
Rationale 1:
Found with the EHR but not found with the CPR are: assists with the work of planning and
delivery of evidence-based care; evidence-based decision support; public health disease
surveillance and reporting, and quality management. The CPR is a comprehensive lifetime
record that includes all information from all specialties.
Rationale 2:
Found with the EHR but not found with the CPR are: assists with the work of planning and
delivery of evidence-based care; evidence-based decision support; public health disease
surveillance and reporting, and quality management. The CPR is a comprehensive lifetime
record that includes all information from all specialties.
Rationale 3:
Found with the EHR but not found with the CPR are: assists with the work of planning and
delivery of evidence-based care; evidence-based decision support; public health disease
surveillance and reporting, and quality management. The CPR is a comprehensive lifetime
record that includes all information from all specialties.
Rationale 4:
Found with the EHR but not found with the CPR are: assists with the work of planning and
delivery of evidence-based care; evidence-based decision support; public health disease
surveillance and reporting, and quality management. The CPR is a comprehensive lifetime
record that includes all information from all specialties.
Rationale 5:
The CPR is a comprehensive lifetime record that includes all information from all specialties.
Found with the EHR but not found with the CPR are: assists with the work of planning and
delivery of evidence-based care; evidence-based decision support; public health disease
surveillance and reporting, and quality management.
Question 17
Personal health record (PHR) security issues relate to HIPAA and physical security of data.
HIPAA only covers PHRs provided by covered entities such as health plans, health care
clearinghouses, and providers. No governmental coverage exists for other sites unless it is at
the state level. To avoid these types of breaches, the American Health Information
Community's consumer empowerment working group made a recommendation. Which of the
following was recommended for PHRs in order to avoid breaches?
1. Deletion of sensitive data
2. Educating the general consumer about PHRs
3. Restricting the number of authorized users
4. A PHR certification process
Correct Answer: 4
Rationale 1:
The consumer empowerment working group of the American Health Information Community
recommends a certification process for PHRs to avoid security breaches.
Rationale 2:
The consumer empowerment working group of the American Health Information Community
recommends a certification process for PHRs to avoid security breaches.
Rationale 3:
The consumer empowerment working group of the American Health Information Community
recommends a certification process for PHRs to avoid security breaches.
Rationale 4:
The consumer empowerment working group of the American Health Information Community
recommends a certification process for PHRs to avoid security breaches.
Question 18
The EHR offers benefits to nurses, physicians, and other health care providers, the health care
enterprise, and most importantly, the consumer. Much must be done before the benefits
associated with the EHR can be realized. Which of the following is one action that has been
proposed by experts?
1. Health care professionals should institute major changes in the way they work.
2. Consumers need education to choose providers based upon appropriate financial and
insurance considerations.
3. Individual consumers should have lesser responsibility for data.
4. Government intervention should promote information exchange among software vendors
and health care systems.
Correct Answer: 4
Rationale 1:
Some experts call for stronger action on the part of the government to promote information
exchange among software vendors and health care systems. They note that competing
software vendors and health care systems have little incentive to exchange information that
might cause them to lose their competitive edge.
Rationale 2:
Some experts call for stronger action on the part of the government to promote information
exchange among software vendors and health care systems. They note that competing
software vendors and health care systems have little incentive to exchange information that
might cause them to lose their competitive edge.
Rationale 3:
Some experts call for stronger action on the part of the government to promote information
exchange among software vendors and health care systems. They note that competing
software vendors and health care systems have little incentive to exchange information that
might cause them to lose their competitive edge.
Rationale 4:
Some experts call for stronger action on the part of the government to promote information
exchange among software vendors and health care systems. They note that competing
software vendors and health care systems have little incentive to exchange information that
might cause them to lose their competitive edge.
Question 19
The electronic health record (EHR) has the potential to integrate all pertinent patient
information into one record. It also has potential to improve the quality of health information,
patient safety, and productivity, contain costs, support research, decrease wait time for
treatment and contribute to the body of health care knowledge. Which of the following are
reasons why traditional paper records on clients no longer meet the needs of today's health
care industry?
1. Paper records are episode-oriented with a separate record for each client visit.
2. Key information may be lost from one episode to the next, jeopardizing patient safety.
3. Only one person can access a paper record at any given time.
4. Different versions of the same information may be stored in several places.
5. Paper records cannot incorporate diagnostic studies that include images and sound.
Correct Answer: 1,2,3,4,5
Rationale 1:
The following are reasons why traditional paper records on clients no longer meet the needs
of today's health care industry:
-Paper records are episode-oriented with a separate record for each client visit.
-Key information, such as allergies, may be lost from one episode to the next, jeopardizing
patient safety.
-Only one person can access a paper record at any given time. Therefore, health care
providers waste time looking for paper records and treatment may be delayed.
-Different versions of the same information may be stored in several places.
-Paper records cannot incorporate diagnostic studies that include images and sound, nor do
they make use of decision support systems.
Rationale 2:
The following are reasons why traditional paper records on clients no longer meet the needs
of today's health care industry:
-Paper records are episode-oriented with a separate record for each client visit.
-Key information, such as allergies, may be lost from one episode to the next, jeopardizing
patient safety.
-Only one person can access a paper record at any given time. Therefore, health care
providers waste time looking for paper records and treatment may be delayed.
-Different versions of the same information may be stored in several places.
-Paper records cannot incorporate diagnostic studies that include images and sound, nor do
they make use of decision support systems.
Rationale 3:
The following are reasons why traditional paper records on clients no longer meet the needs
of today's health care industry:
-Paper records are episode-oriented with a separate record for each client visit.
-Key information, such as allergies, may be lost from one episode to the next, jeopardizing
patient safety.
-Only one person can access a paper record at any given time. Therefore, health care
providers waste time looking for paper records and treatment may be delayed.
-Different versions of the same information may be stored in several places.
-Paper records cannot incorporate diagnostic studies that include images and sound, nor do
they make use of decision support systems.
Rationale 4:
The following are reasons why traditional paper records on clients no longer meet the needs
of today's health care industry:
-Paper records are episode-oriented with a separate record for each client visit.
-Key information, such as allergies, may be lost from one episode to the next, jeopardizing
patient safety.
-Only one person can access a paper record at any given time. Therefore, health care
providers waste time looking for paper records and treatment may be delayed.
-Different versions of the same information may be stored in several places.
-Paper records cannot incorporate diagnostic studies that include images and sound, nor do
they make use of decision support systems.
Rationale 5:
The following are reasons why traditional paper records on clients no longer meet the needs
of today's health care industry:
-Paper records are episode-oriented with a separate record for each client visit.
-Key information, such as allergies, may be lost from one episode to the next, jeopardizing
patient safety.
-Only one person can access a paper record at any given time. Therefore, health care
providers waste time looking for paper records and treatment may be delayed.
-Different versions of the same information may be stored in several places.
-Paper records cannot incorporate diagnostic studies that include images and sound, nor do
they make use of decision support systems.
Question 20
Electronic medical record (EMR) result reporting and data repository components include
unstructured data. Which of the following are examples of unstructured data?
1. Automated laboratory results
2. History and physical
3. Consultation findings
4. Magnetic resonance imaging
5. A social services text report
Correct Answer: 2,3,5
Rationale 1:
Examples of unstructured EMR data are history and physical, social services text report, and
consultation findings. Unstructured data do not follow any particular format. Other examples
are operative reports, and discharge summaries. The EMR also includes structured data, those
that follow a predefined format and are often presented as discrete data elements. A primary
example is laboratory results from an automated laboratory information system. Magnetic
resonance imaging is an example of another type of structured data that may be included in
the EMR.
Rationale 2:
Examples of unstructured EMR data are history and physical, social services text report, and
consultation findings. Unstructured data do not follow any particular format. Other examples
are operative reports, and discharge summaries. The EMR also includes structured data, those
that follow a predefined format and are often presented as discrete data elements. A primary
example is laboratory results from an automated laboratory information system. Magnetic
resonance imaging is an example of another type of structured data that may be included in
the EMR.
Rationale 3:
Examples of unstructured EMR data are history and physical, social services text report, and
consultation findings. Unstructured data do not follow any particular format. Other examples
are operative reports, and discharge summaries. The EMR also includes structured data, those
that follow a predefined format and are often presented as discrete data elements. A primary
example is laboratory results from an automated laboratory information system. Magnetic
resonance imaging is an example of another type of structured data that may be included in
the EMR.
Rationale 4:
Examples of unstructured EMR data are history and physical, social services text report, and
consultation findings. Unstructured data do not follow any particular format. Other examples
are operative reports, and discharge summaries. The EMR also includes structured data, those
that follow a predefined format and are often presented as discrete data elements. A primary
example is laboratory results from an automated laboratory information system. Magnetic
resonance imaging is an example of another type of structured data that may be included in
the EMR.
Rationale 5:
Examples of unstructured EMR data are history and physical, social services text report, and
consultation findings. Unstructured data do not follow any particular format. Other examples
are operative reports, and discharge summaries. The EMR also includes structured data, those
that follow a predefined format and are often presented as discrete data elements. A primary
example is laboratory results from an automated laboratory information system. Magnetic
resonance imaging is an example of another type of structured data that may be included in
the EMR.
Question 21
The mere implementation of an electronic medical record (EMR) does not guarantee that
benefits will be achieved. Which of the following can affect data integrity?
1. System failure
2. Data analysis
3. Data downloading
4. Data mining
Correct Answer: 1
Rationale 1:
Data integrity can be compromised in three ways: incorrect entry, data tampering, and system
failure. In general, data integrity can be improved by implementing security measures,
including the use of audit trails, as well as the development of detailed procedures and
policies.
Rationale 2:
Data integrity can be compromised in three ways: incorrect entry, data tampering, and system
failure. In general, data integrity can be improved by implementing security measures,
including the use of audit trails, as well as the development of detailed procedures and
policies. Data analysis, downloading, and mining do not compromise data integrity.
Rationale 3:
Data integrity can be compromised in three ways: incorrect entry, data tampering, and system
failure. In general, data integrity can be improved by implementing security measures,
including the use of audit trails, as well as the development of detailed procedures and
policies. Data analysis, downloading, and mining do not compromise data integrity.
Rationale 4:
Data integrity can be compromised in three ways: incorrect entry, data tampering, and system
failure. In general, data integrity can be improved by implementing security measures,
including the use of audit trails, as well as the development of detailed procedures and
policies. Data analysis, downloading, and mining do not compromise data integrity.
Question 22
Which of the following statements about meaningful use is correct?
1. Meaningful use will provide invaluable information that will define the numbers of staff
members needed at the bedside.
2. Meaningful use will provide invaluable information that will improve patient outcomes
and population health changing many current practices as we transform our health care
delivery system.
3. Meaningful use is an ongoing process and not an issue associated with the EHR.
4. Meaningful use is an issue that must be addressed before implementing any upgrade.
Correct Answer: 2
Rationale 1:
Meaningful use will provide invaluable information that will improve patient outcomes and
population health changing many current practices as we transform our health care delivery
system.
Rationale 2:
Meaningful use will provide invaluable information that will improve patient outcomes and
population health changing many current practices as we transform our health care delivery
system.
Rationale 3:
Meaningful use will provide invaluable information that will improve patient outcomes and
population health changing many current practices as we transform our health care delivery
system.
Rationale 4:
Meaningful use will provide invaluable information that will improve patient outcomes and
population health changing many current practices as we transform our health care delivery
system.
Question 23
The computer-based patient record (CPR) is a comprehensive lifetime record that includes all
information from all specialties. Most of the data included in the CPR is which of the
following?
1. Structured data
2. Unstructured data
3. Fragmented data
4. Complete data
Correct Answer: 1
Rationale 1:
The computer-based patient record (CPR) is a comprehensive lifetime record that includes all
information from all specialties. Most of the data included in the CPR are structured data.
Other data formats may also be linked to the CPR, including dictation and transcription,
images, video, and text. These data, and collective data from all systems, are stored and
managed in the clinical data repository.
Rationale 2:
The computer-based patient record (CPR) is a comprehensive lifetime record that includes all
information from all specialties. Most of the data included in the CPR are structured data.
Other data formats may also be linked to the CPR, including dictation and transcription,
images, video, and text. These data, and collective data from all systems, are stored and
managed in the clinical data repository.
Rationale 3:
The computer-based patient record (CPR) is a comprehensive lifetime record that includes all
information from all specialties. Most of the data included in the CPR are structured data.
Other data formats may also be linked to the CPR, including dictation and transcription,
images, video, and text. These data, and collective data from all systems, are stored and
managed in the clinical data repository.
Rationale 4:
The computer-based patient record (CPR) is a comprehensive lifetime record that includes all
information from all specialties. Most of the data included in the CPR are structured data.
Other data formats may also be linked to the CPR, including dictation and transcription,
images, video, and text. These data, and collective data from all systems, are stored and
managed in the clinical data repository.
Question 24
Which of the following best describes the electronic medical record (EMR)?
1. Legal record created in hospitals
2. Legal record created by vendors
3. An electronic stand alone database
4. Method to identify outcomes
Correct Answer: 1
Rationale 1:
The Healthcare Information and Management Systems Society (HIMSS) defined the
electronic medical record (EMR) as the "legal record created in hospitals and ambulatory
environments that is the source of data for the EHR" (2006).
Rationale 2:
The Healthcare Information and Management Systems Society (HIMSS) outlined the
differences between the terms electronic medical record and electronic health record. HIMSS
defined the electronic medical record (EMR) as the "legal record created in hospitals and
ambulatory environments that is the source of data for the EHR" (2006).
Rationale 3:
The Healthcare Information and Management Systems Society (HIMSS) defined the
electronic medical record (EMR) as the "legal record created in hospitals and ambulatory
environments that is the source of data for the EHR" (2006).
Rationale 4:
The Healthcare Information and Management Systems Society (HIMSS) defined the
electronic medical record (EMR) as the "legal record created in hospitals and ambulatory
environments that is the source of data for the EHR" (2006).
Question 25
The relationship between meaningful use and the adoption of the EHR in hospitals, physician
offices, and other settings is best described as which of the following?
1. The meaningful use requirement must be considered before beginning the development
process.
2. The meaningful use requirement is achieved with the adoption and use of the EHR system
as part of the daily routine.
3. The meaningful use requirement is unique to every health care provider.
4. The meaningful use requirement and use of EHR systems are unrelated.
Correct Answer: 2
Rationale 1:
The meaningful use requirement is a major driver in the adoption and use of EHR systems
across U.S. health care delivery systems and physician practices today (Bell & Thornton
2011; Hewlett Packard, 2010). The meaningful use requirement is being implemented in
stages.
Rationale 2:
The fully developed EHR necessitates mandatory use of computers by caregivers as part of
their daily routine. The meaningful use requirement is a major driver in the adoption and use
of EHR systems across U.S. health care delivery systems and physician practices today (Bell
& Thornton 2011; Hewlett Packard, 2010). The meaningful use requirement is being
implemented in stages.
Rationale 3:
The meaningful use requirement is a major driver in the adoption and use of EHR systems
across U.S. health care delivery systems and physician practices today (Bell & Thornton
2011; Hewlett Packard, 2010). The meaningful use requirement is being implemented in
stages.
Rationale 4:
The meaningful use requirement is a major driver in the adoption and use of EHR systems
across U.S. health care delivery systems and physician practices today (Bell & Thornton
2011; Hewlett Packard, 2010). The meaningful use requirement is being implemented in
stages.
Question 26
_________________________ would permit the uniform capture of data required to build a
longitudinal record comprised of integrated information systems from multiple vendors.
Correct Answer: Data exchange standards
Rationale:
Data exchange standards would permit the uniform capture of data required to build a
longitudinal record comprised of integrated information systems from multiple vendors. Most
CPR data are structured, yet additional formats can be linked to the system offering
additional data.
Question 27
The goals of implementing the EHR in all health care systems are fraught with a number of
roadblocks. The largest barrier facing most institutions is which of the following?
1. The lack of fully trained professional staff
2. A technology committee that cannot agree on the institution's needs
3. Indecision regarding the choice of vendors
4. Cost
Correct Answer: 4
Rationale 1:
Training is part of the implementation phase of the life cycle.
Rationale 2:
The technology committee debates and investigates the needs of the organization. Based on
group dynamics, the committee will not always agree on issues, however, this should not
block progress.
Rationale 3:
If the committee has used a decision making tool or grid to analyze the RFP responses, the
decision is left to administration.
Rationale 4:
The cost of a fully functioning computer system strains the budget. This may prevent
organizations from full automation.
Question 28
Which of the following are considered impediments to a fully functional electronic health
record (EHR) system?
1. Development of an electronic infrastructure
2. Cost
3. Common vocabulary
4. Caregiver compliance
5. Privacy
Correct Answer: 1,2,5
Rationale 1:
Legal issues surrounding the discovery of medical information
Rationale 2:
Legal issues surrounding the discovery of medical information
Rationale 3:
Legal issues surrounding the discovery of medical information
Rationale 4:
Legal issues surrounding the discovery of medical information
Rationale 5:
Legal issues surrounding the discovery of medical information
Test Bank for Handbook of Informatics for Nurses and Healthcare Professionals
Toni Lee Hebda, Patricia Czar, Theresa Calderone
9780132574952, 9780132959544, 9780134711010, 9780131512627, 9780130311023, 9780805373264, 9780135205433, 9780135043943
