This Document Contains Chapters 1 to 2 Chapter 1 Question 1 Which entity first identified capturing data at the point of care as a key criterion for an EHR? 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Institute of Medicine (IOM) 3. Computer-based Patient Record Institute (CPRI) 4. Health Information Technology for Economic and Clinical Health (HITECH) Act Answer: 3 Rationale 1: The HIPAA Security Rule did not define an EHR but established protection for all personally identifiable health information stored in electronic format Rationale 2: the IOM report put forth a set of eight core functions that an EHR should be capable of performing Rationale 3: CPRI was an early contributor to EHR systems, and identified three key criteria for EHR, including capturing data at the point of care, integrating data from multiple sources and providing decision support Rationale 4: HITECH Act promotes the widespread adoption of EHR and authorizes Medicare incentive payments to doctors and hospitals using a certified HER Question 2 Which of the following is the best definition of electronic health records? 1. Any information that relates to the past, present, or future physical condition of a person that is stored in an electronic format. 2. The portions of a client’s medical records that are stored in a computer system as well as the functional benefits derived from having an electronic health record. 3. Client information that is stored electronically and may be accessed by both the client and the client’s healthcare providers on demand. 4. Any healthcare information that is stored by computer. Answer: 2 Rationale 1: This definition is not the broadest; the EHR is not just what is stored, but what can be done with it Rationale 2: The IOM and CPRI suggest that the EHR is not just what is stored, but the functional benefits derived from having an electronic health record Rationale 3: This definition is limited Rationale 4: This definition is limited Question 3 The ONC developed which of the following strategies to meet their goal of informing clinical practice? 1. Fostering regional collaborations 2. Encouraging use of PHR 3. Accelerating research and dissemination of evidence 4. Promoting EHR diffusion in rural and underserved areas Answer: 4 Rationale 1: Fostering regional collaborations is part of the ONC goal of interconnecting clinicians Rationale 2: Encouraging the use of PHR is part of the ONC goal of personalizing care Rationale 3: In an effort to improve population health, one of the ONC strategies is to accelerate research and disseminate evidence Rationale 4: As part of the goal of informing clinical practice, the ONC strategies include promoting EHR diffusion in rural and underserved areas, incentivizing EHR adoption, and reducing the risk of EHR clinicians who purchase HER Question 4 Why would a small primary care practice need to know about the HITECH Act? 1. Because it makes funding available to help the practice implement a certified EHR 2. Because it will reduce Medicare payments by five percent if the use of paper charts continue to be used in 2013 3. Because it offers financial incentives for implementing an EHR before 2015 4. Because it requires medical practices to offer telemedicine to clients by 2020 Answer: 3 Rationale 1: Financial incentives will be offered, as well as penalties; funding is not part of the HITECH act Rationale 2: After 2020, a provider still using paper charts will have payments reduced by 5 percent Rationale 3: Providers that implement and have meaningful use of a certified EHR prior to 2015 are eligible for incentives Rationale 4: Telemedicine is not part of the HITECH Act Question 5 Which of the following is not one of the IOM criteria for EHRs? 1. Connectivity between multiple care providers 2. Management of administrative processes and reporting 3. Statistical collection and reporting related to population health 4. Capture data at the point of care Answer: 4 Rationale 1: Electronic communication among care partners can enhance client safety Rationale 2: Electronic scheduling and reporting tools increase the efficiency of healthcare organizations and provide better, timelier service to clients Rationale 3: Public and private sector reporting requirements at the federal, state, and local levels for client safety and quality are more easily met with computerized data Rationale 4: The Computer-based Client Record Institute identified capturing data at the point of care as a key criteria for an HER Question 6 The nurse reviews the client registration form, and asks for more detail about the chief complaint, which is: 1. A summary of the client’s symptoms 2. A record of the client’s vital signs 3. The main reason a client seeks care 4. The nurse’s assessment of what is wrong with the client Answer: 3 Rationale 1: A summary of the client’s symptoms is the subjective portion of the clinical interaction note Rationale 2: The client’s vital signs are objective data Rationale 3: The chief complaint is the reason the client is seeking care Rationale 4: The assessment is the nurse or clinician’s application of his or her training to the subjective and objective findings, and arriving at a decision of what might be the cause of the client’s condition Question 7 The nurse is caring for a client with upper respiratory and sinus symptoms. The provider writes a prescription on a prescription pad. Which of the following is reasonable to infer about the client records at the provider’s office based on this interaction? 1. They may be either paper or electronic because EHR systems require a handwritten prescription for the medical chart. 2. They are electronic records but the software does not support electronic prescription submission. 3. They are paper records because electronic records require electronic submission of prescriptions. 4. They may be either paper or electronic but your doctor simply prefers to write out her or his prescriptions. Answer: 4 Rationale 1: the EHR does not require a handwritten prescription Rationale 2: The office fully using an EHR will not have paper prescriptions Rationale 3: The office using a paper records will not have electronic submission of prescriptions Rationale 4: The office may not be using EHR fully, and may have paper or written prescriptions Question 8 Which of the following is not true about an inpatient chart? 1. It only contains information related to the client’s current stay. 2. Its central element is the physician’s exam note. 3. It includes more information than an outpatient chart. 4. It includes nurse’s notes that indicate the client’s response to treatment. Answer: 2 Rationale 1: The inpatient chart generally contains information related to the current stay; old charts will have records from previous admissions Rationale 2: The central elements of the chart are the physician’s orders and nurses’ notes indicating the client’s response Rationale 3: The quantity of data in an inpatient chart is likely to be much larger than an outpatient chart Rationale 4: The inpatient chart includes nurses’ notes that indicate the client’s response to treatment; the central element in the outpatient chart is the physician’s exam note Question 9 Which of the following is a characteristic of an EHR system used by a medical office? 1. It incorporates computer systems from many different vendors. 2. It is the principal electronic medical record. 3. It must be accessible to any specialists who are also treating the client. 4. It requires clinicians to use an interface to view data from different systems. Answer: 2 Rationale 1: The EHR in the medical office will usually be from a single vendor Rationale 2: The EHR in a medical office can be accessed by multiple providers and is the client’s main EHR Rationale 3: The office EHR may or may not be accessible to other specialists who are treating the client Rationale 4: The office EHR allows the provider to view data from multiple sources that are merged into the EHR automatically Question 10 The nurse demonstrates which of the following as an example of point-of-care documentation? 1. A nurse enters a client’s vital signs into the client’s record at the end of the shift. 2. A transcriptionist types an encounter note and sends it to the physician. 3. A nurse practitioner enters the encounter data during the client’s visit. 4. A nurse practitioner creates an exam note from memory while the client gets dressed. Answer: 3 Rationale 1: End of shift documentation leaves room for error, as the clinician may omit data Rationale 2: Transcribed encounter notes are not entered into the EHR at the time of service Rationale 3: Entering encounter data during the client’s visit increases efficiency and data accuracy Rationale 4: Creating an exam not from memory leaves room for error, and is less efficient Question 11 One drawback of using an EHR on a tablet PC that is not a problem on a laptop is that it: 1. is easy to drop. 2. runs on batteries. 3. is harder for IT departments to update. 4. lacks a keyboard. Answer: 4 Rationale 1: Both the tablet PC and the laptop are easy to drop Rationale 2: Both the tablet PC and laptop may run on batteries Rationale 3: Both the tablet PC and laptop can be updated easily Rationale 4: Most tablet PCs do not have a keyboard for touch-typing; it may have handwriting recognition or speech recognition Question 12 Both the IOM and CPRI share which of the following EHR criteria recommendations? 1. Data capture at the point of care 2. Electronic communication and connectivity 3. Provision of decision support 4. Client support Answer: 3 Rationale 1: The CPRI identified capturing data at the point of care as a key criteria for an EHR Rationale 2: The IOM identified electronic communication with clients and other providers as a key criteria for an EHR Rationale 3: Both the CPRI and the IOM identified decision support, including prevention, prescribing of drugs, diagnosis and management as a key criteria for an EHR Rationale 4: The IOM identified client support, such as computer based education, as a key criteria for an HER Question 13 The nurse explains to a client that one of the improvements that point of care documentation provides in the delivery of healthcare is: 1. It saves time and money by eliminating the cost of dictation and transcription. 2. It prevents a clinician from signing an encounter note before the client leaves the office. 3. It ensures that all information required for referrals is available immediately. 4. It gives the client a chance to make corrections to his or her medical record. Answer: 3 Rationale 1: The use of point of care documentation saves money by decreasing the potential for costly errors Rationale 2: The clinician can sign the electronic encounter note prior to the client leaving the office Rationale 3: All information is available immediately to referrals Rationale 4: The point of care documentation system typically does not allow the client the chance to make changes in his or her medical record Question 14 Which of the following best defines the term eligible professional? 1. Any clinician who works directly with clients when providing care and is therefore bound by HIPAA mandates. 2. Anyone who has been granted access to protected health information in electronic form. 3. A credentialed healthcare professional that is in good standing with a medical board and qualified to practice in a state. 4. A healthcare provider who is considered entitled to receive incentive payments under the HITECH Act. Answer: 4 Rationale 1: HIPAA mandates apply to all who may have access to a client’s PHI Rationale 2: PHI access can be granted to many different types of entities, such as admissions staff or insurance companies, not only to professionals Rationale 3: A licensed health care professional is one who is in good standing with a medical board and qualifies to practice in a state Rationale 4: Eligible professionals are those who have met 20 of 25 meaningful use objectives as published by CMS Question 15 Which of the following considered an optional, rather than a core, meaningful objective for hospitals when fulfilling the CMS meaningful use criteria? 1. CPOE 2. Drug-formulary checks 3. Maintain active medication list 4. Record smoking status for clients 13 years or older Answer: 2 Rationale 1: Computerized order entry systems is identified as a core objective Rationale 2: Drug formulary checks are an optional eligible professional meaningful use objective; a total of 5 of the optional 10 are required Rationale 3: Maintaining an active medication list and medication allergy list are core objectives for the eligible professional to meet for meaningful use to be established Rationale 4: Recording the client’s smoking status is a core requirement Question 16 Which of the following certifies an EHR system? 1. ONC-ATCB 2. CPRI 3. CHCS II 4. AHIMA Answer: 1 Rationale 1: The Office of the National Coordinator for Health Information Technology (ONC) Authorized Testing and Certification Body (ATCB) certifies an EHR that providers must adopt in order to meet the meaningful use guidelines Rationale 2: The Computer-based Client Record Institute was an early contributor to the thinking on EHR systems Rationale 3: The CHCS II does not certify an EHR system Rationale 4: The American Health Information Management Association, in conjunction with other associations, developed the Certified Commission for Healthcare Information Technology to reduce the risk to providers adopting an EHR, but does not certify individual EHRs. Question 17 Which of the following statements about electronic health records is true? 1. The idea for electronic health records first originated with the Health Insurance Portability and Accountability Act. 2. The Computer-based Patient Record Institute outlined eight core functions that any EHR should be able to perform. 3. It has primarily been physicians who have led the charge in the impetus behind developing a national EHR system. 4. The HITECH Act is promoting the widespread adoption of electronic health records. Answer: 4 Rationale 1: The IOM sponsored studies and created reports that led the way to the concepts we have in place for EHRs prior to the implementation of HIPAA Rationale 2: The IOM report put forth a set of eight core functions that an EHR should be capable of performing Rationale 3: Health care safety, costs, and a changing society have been the impetus behind developing a national EHR system Rationale 4: The HITECH Act authorized Medicare to make incentive payments to doctors and hospitals that use a certified HER Question 18 Which of the following organizations created a strategy that tied purchase of group health insurance benefits to quality care standards? 1. AHIMA 2. Leapfrog Group 3. Kaiser Permanente 4. Agency for Healthcare Research and Quality Answer: 2 Rationale 1: The American Health Information Management Association is a health information association Rationale 2: Employers who sponsored employee health insurance programs got frustrated by the increasing costs of health insurance benefits, and promoted CPOE as a means of reducing errors Rationale 3: Kaiser Permanente is an HMO Rationale 4: The AHRQ supports a variety of efforts targeted at reducing medical errors Question 19 Which of the following is not considered part of the workflow in a medical office that uses an EHR system? 1. The workflow process begins when the client requests an appointment. 2. The clinician dictates her exam notes at the conclusion of the client encounter. 3. The client discusses his symptoms with the nurse. 4. The client leaves the office with a printed copy of the encounter. Answer: 2 Rationale 1: The client either phones the medical office, or uses the Internet to request an appointment, which is electronically initiated by the staff Rationale 2: In an EHR office, the clinician enters information into the record at the point of service Rationale 3: The client discusses his symptoms with the nurse at the medical office Rationale 4: The clinician or other office staff will print a completed copy of the encounter, which will include any client education necessary, or tests that are ordered. Question 20 Which of the following is not true of speech recognition software? 1. Recognizes verbal commands to operate the software. 2. Recognizes the patterns in human speech as words and turns them into text. 3. Replaces the nurse with a computer software program. 4. Frequently used in specialties such as radiology and pathology. Answer: 3 Rationale 1: Speech recognition allows providers to document observations and navigate software without external devices Rationale 2: Speech recognition software recognized patterns in human speed; medical language models can recognize medical terms Rationale 3: Speech recognition replaces other external input devices, not professional staff Rationale 4: Speech recognition software can recognize verbal commands to operate software, and allows the radiologist or pathologist to open orders, save reports, zoom images or change contrast without using his or her hands Question 21 The nurse explains to the client who is being admitted to the acute care facility for the third time in six months that the results management function of the EHR allows providers to: Standard Text: Select all that apply. 1. recognize and treat problems more quickly 2. reduce the number of tests ordered 3. recognize abnormal results more quickly 4. utilize established critical links between providers and providers and clients to improve care coordination 5. reduce the number of errors in medication dose and frequency Answer: 1, 2, 3, 4 Rationale 1: The results management function of an EHR allows results to be accessed more easily, reducing the lag time between testing and results Rationale 2: the automated display of previous test results makes it possible to reduce redundant and additional testing Rationale 3: Having electronic results can allow for better interpretation and for easier detection of abnormalities, thereby ensuring appropriate follow-up Rationale 4: The results management function of the EHR allow access to electronic consults and client consents can establish critical links and improve coordination among multiple providers, as well as between provider and client Rationale 5: The order management function, CPOE, used for medications reduce the number of errors in medication dose and frequency, drug allergies and drug-drug interaction Question 22 The nurse uses the electronic communication function of the EHR to: Standard Text: Select all that apply. 1. Communicate with the pharmacy 2. email clients and providers 3. Communicate with the laboratory 4. View prevention guidelines 5. Review drug-drug interactions Answer: 1, 2, 3 Rationale 1: Communication with the facility pharmacy, as well as the client’s pharmacy is secure in the EHR Rationale 2: Secure email and web messaging have been shown to be effective in facilitating communication both among providers and with clients Rationale 3: Laboratory results can be reviewed, with instant alerts sent to providers for abnormal results Rationale 4: Viewing prevention guidelines is a facet of the decision support function of the EHR Rationale 5: Reviewing drug-drug interactions is a facet of the CPOE function of the HER Question 23 The nurse understands that the primary force driving the adoption of EHR as a standard of practice is: 1. Health costs 2. Medical errors 3. Clients relocation 4. Provider request Answer: 2 Rationale 1: A study by the Center for Information Technology Leadership suggested that $44 billion could be saved by installing CPOE in ambulatory settings; this is not the primary issue Rationale 2: Medical errors contribute to the deaths of at least an estimated 44,000 people annually, as well as other preventable medical errors that are related to a variety of factors, including decentralized and fragmented healthcare Rationale 3: The changes in the way we live, with frequent relocation of clients and changing of providers, contributes the need for clients to be able to transfer medical records; this is not the primary issue Rationale 4: Providers were not instrumental in the adoption of the HER Question 24 The client is complaining to the nurse about the need for a computer in the examination room. The nurse explains that the EHR is important because: Standard Text: Select all that apply. 1. Legibility 2. The ability to search the records is facilitated 3. Sharing information 4. Ability to locate records 5. Storage needs Answer: 1, 2, 3, 4 Rationale 1: Handwritten records are often cryptic or illegible Rationale 2: The ability to search the records is facilitated, which may improve client care Rationale 3: The ability to share information with different facilities and providers is facilitated Rationale 4: The ability of multiple providers to access the EHR at the same time is facilitated by an EHR Rationale 5: Storage needs are not an important concern leading to the use of the HER Question 25 In the office that uses paper charts, how many times is the paper chart touched by personnel, including the provider, during a visit for an upper respiratory infection that requires a chest x-ray? 1. 3 or less 2. at least 6 3. 5 or less 4. 4 Answer: 2 Rationale 1: More than three people in the office touch the chart Rationale 2: 1)The chart is pulled from the files; 2)the client updates the registration form which is put back into the chart; 3) the nurse takes a quick history of the problem, and documents the vital signs; 4) the provider reviews the vital signs, then examines the client; 5) the provider documents diagnosis and plan; 6) nurse notes plan and calls radiology provider, and documents in the chart; 7) the chart is filed; 8) the x-ray report is sent to the office, where it is filed Rationale 3: More than 5 people touch the chart Rationale 4: More than 4 people touch the chart Question 26 The major difference between the outpatient and inpatient client record is: 1. Each client has his or her own chart 2. The quantity of data in an outpatient chart is much larger 3. The central element of the inpatient chart is the physician’s exam note 4. The inpatient chart contains only information related to the current stay Answer: 4 Rationale 1: Each client has his or her own chart in both settings Rationale 2: The quantity of data in an inpatient chart is much larger Rationale 3: The central element of the outpatient chart is the physician’s exam note Rationale 4: The outpatient chart includes information from all the client’s previous visits Question 27 The benefits of using a computer workstation include: 1. Uses minimal space 2. reliability 3. wireless networking is faster 4. mobility Answer: 2 Rationale 1: Workstations take up a lot of space in traditionally small work space Rationale 2: Workstations are cheap, reliable, and dependable Rationale 3: Wired networks usually are faster with the workstation Rationale 4: Workstations are in fixed location Question 28 One advantage of the workstation over a tablet PC is: 1. Portability 2. Screen resolution 3. Handwriting recognition 4. Mouse less interface Answer: 2 Rationale 1: The workstation is not portable, while the tablet PC is portable Rationale 2: The workstation can support higher screen resolution than any other device, making it the best choice for radiologists, and others who read diagnostic quality images of x-rays, CAT scans Rationale 3: Handwriting recognition is a feature that can be found on tablet PCs Rationale 4: The mouse-less interface is a characteristic of the tablet PC Question 29 Laptop computers have which of the following disadvantages compared to the workstation: Standard Text: Select all that apply. 1. Security concerns 2. Rapid obsolescence 3. Portability 4. Battery life 5. Accidental damage Answer: 1, 2, 4, 5 Rationale 1: Wireless networking gives rise to the concern that electronic PHI can be intercepted Rationale 2: Laptops have only limited capability for hardware upgrades Rationale 3: Portability is an advantage that the laptop has over the workstation Rationale 4: The laptop typically runs on batteries that require recharging after 2-4 hours of use Rationale 5: The laptop is more susceptible to being dropped, lost or damaged Question 30 The need for EHR and better connectivity between EHR systems is important because: 1. Physicians want to streamline client care 2. Providers need access to a client’s medical history in case of emergency 3. It is difficult to get care on weekends 4. It is mandated by the ONC Answer: 2 Rationale 1: Physicians and everyone involved in client care are interested in safer healthcare Rationale 2: Providers need access to medical history; emergency situations may occur at a time when an office is closed, and traditional records are difficult to access Rationale 3: Quality care should be available seven days a week Rationale 4: The mandate by the ONC is not the most important reason to implement an HER Chapter 2 Question 1 Which of the following is not a functional benefit for an EHR as defined by the IOM? 1. Trend analysis 2. Health maintenance 3. Discrete data 4. Alerts Answer: 3 Rationale 1: Trend analysis, health maintenance, alerts and decision supports are four of the functional benefits identified by the IOM. Rationale 2: Trend analysis, health maintenance, alerts and decision supports are four of the functional benefits identified by the IOM. Rationale 3: Discrete data is a form of stored information in an EHR that is easiest for the computer to use Rationale 4: Trend analysis, health maintenance, alerts and decision supports are four of the functional benefits identified by the IOM. Question 2 Which of the following is an example of a digital image that may be part of an electronic medical record? 1. Fielded data 2. Coded data 3. Transcribed exam notes 4. Annotated drawings Answer: 4 Rationale 1: Fielded data is an example of discrete data, which is a form of stored information in an EHR that is the easiest for the computer to use Rationale 2: Coded data is fielded data that also contains codes in addition to or in place of descriptive text Rationale 3: Transcribed exam notes are an example of text files Rationale 4: Annotated drawings are diagnostic images, and are an example of digital images Question 3 Which of the following statements is true about discrete data that is stored in an EHR system? 1. A person is needed to interpret its meaning. 2. It must first be imported from outside text files. 3. It requires little storage space. 4. It is only useful if it is codified. Answer: 3 Rationale 1: Digital images require a human to interpret the meaning of the content Rationale 2: Text files are obtained in the EHR by importing text files from outside sources Rationale 3: Discrete data can be instantly searched, retrieved, and combined or reported in different ways, and takes up less space than narrative notes or images Rationale 4: Coded data is a type of discrete data Question 4 Text data that is stored in an EHR system is least useful for performing which of the following functions? Standard Text: Select all that apply. 1. Decision support 2. Trend analysis 3. Research 4. Diagnosis 5. Alerts Answer: 1, 2, 5 Rationale 1: Using text data for decision support is seldom initiated because the search capability is slow Rationale 2: Using text data for trend analysis is not used because the search capability is slow Rationale 3: Text data is useful for research as it can be searched by the computer Rationale 4: Text data is not used for diagnosis as the search results are often ambiguous Rationale 5: Alerts are seldom generated by text data as the search capability is slow, and the results often ambiguous Question 5 Which of the following is an example of a result finding? 1. white male 2. 20120331 3. gall bladder 4. normal urine protein Answer: 4 Rationale 1: White male is an example of a physical examination finding Rationale 2: 20120331 is an example of a coded finding Rationale 3: Gall bladder is an example of a history or physical exam finding Rationale 4: Normal urine protein is an example of a laboratory test result finding Question 6 Which of the following is not one of the six main categories that the MEDCIN nomenclature uses to organize findings? 1. Body Structure 2. Symptoms 3. Physical Examination 4. Therapy Answer: 1 Rationale 1: Body structure is not a clinical concept or finding Rationale 2: Symptoms are one of the broad categories in the MEDCIN nomenclature Rationale 3: Physical exam is one of the broad categories in the MEDCIN nomenclature Rationale 4: Therapy (treatment) is one of the six broad categories in the MEDCIN nomenclature Question 7 What is the NANDA-I code set used to categorize? 1. Laboratory test results 2. Biomedical information 3. Nursing diagnoses 4. Point-of-care documentation Answer: 3 Rationale 1: Laboratory results are coded by LOINC Rationale 2: UMLS can be used to retrieve and integrate biomedical information and provide cross-references among selected vocabularies Rationale 3: NANDA-I stands for the North American Nursing Diagnosis Association International and is a system of classification of 206 Nursing Diagnoses Rationale 4: NIC (Nursing Interventions Classifications) is designed for use at the point of care to document care planning and nursing practices Question 8 You have just imported an x-ray for a client into an image system; this means: 1. the image has been successfully cataloged. 2. you need to use OCR software to catalog this image. 3. you need to complete the cataloging process by adding the client’s name. 4. you need to enter identifying data about the document into the computer. Answer: 4 Rationale 1: The image is cataloged when the image is captured and data is entered into the computer about the document such as the date, client, provider, and type of image Rationale 2: OCR (Optical Character Recognition) software can recognize text characters in images, and is not typically used in health care Rationale 3: Only adding the client’s name does not complete the cataloging process Rationale 4: Identifying data, such as date, client, provider, and type of image are necessary for complete cataloging of an image Question 9 Which of the following is not true of a Picture Archival Communication System (PAC)? 1. It imports digital images into the EHR system. 2. It associates images with the client EHR record. 3. It is separate from the EHR system. 4. It is used to archive diagnostic images. Answer: 1 Rationale 1: a digital imaging system brings paper documents into the EHR Rationale 2: PAC (Picture Archival and Communication System) associates diagnostic images with the EHR Rationale 3: The PAC is a separate system from the EHR that can be used to link images to the EHR Rationale 4: The PAC is used to archive digital images for use by providers at a later time Question 10 Your medical office is implementing an EHR system and needs to add numerous paper charts into the new document/image system. The best course of action would be to: 1. scan all of the printed pages into the new system. 2. keep the paper charts, but begin entering all new information electronically. 3. import the word processing files from any transcribed dictation as text records. 4. hire transcriptionists to retype all of the old information into the EHR. Answer: 3 Rationale 1: Scanning printed pages is not the best course of action; scanned documents can be cumbersome to read Rationale 2: Eventually the facility will need to bring old paper charts into the Document/Image system Rationale 3: Importing the word processing files as text records increases the amount of the EHR that is text data; text data records are searchable, and can be dynamically reformatted for display on smaller devices such as mobile phones Rationale 4: Transcribing the information does not retain the original records, and allows for human error Question 11 A text file would be produced for upload to an EHR in which of the following examples? 1. A medical assistant scans and catalogs a copy of a client’s test results. 2. A clinician selects a protocol through a client chart at the point-of-care. 3. A radiology technician links to a copy of an X-ray stored in a PAC. 4. A medical transcriptionist types exam notes using a word processor. Answer: 4 Rationale 1: Scanning and cataloging are actions taken with digital image data Rationale 2: Protocols are used by clinicians for decision support; they are standard plans of therapy established for different conditions, and when the clinician has diagnosed a client with a condition, the appropriate protocol appears on the EHR screen and all therapies are ordered with a click of the mouse Rationale 3: A copy of an x-ray is a digital image Rationale 4: Text files are obtained in the EHR by importing word processing files from outside sources Question 12 Which of the following statements about imported text data is false? 1. The text data is searchable by computer. 2. The text data may be incorporated into the EHR system. 3. The text document will dynamically resize itself when viewed on a handheld device. 4. The text data is codified by the EHR once it has been imported. Answer: 4 Rationale 1: Text data is searchable by computer, but may be slow Rationale 2: Text data may be entered directly into the EHR or imported into the EHR Rationale 3: Text data may be entered directly into the EHR or imported into the EHR Rationale 4: Text data is not codified data Question 13 Which of the following standards would enable a hospital that uses many different systems to integrate data from all of these systems in a cohesive way? 1. DICOM 2. HL7 3. PAC 4. IMH Answer: 2 Rationale 1: DICOM is the standard for communication between diagnostic imaging equipment and the image processing software, and is the most widely used format for storing and sending diagnostic images Rationale 2: Health Level 7 (HL7) is the leading messaging standard used by healthcare computer systems to exchange information Rationale 3: Picture Archiving and Communication System (PAC) links the diagnostic image to the client EHR Rationale 4: IMH or instant medical history is client/client entered data that is entered via a secure website by the client into the EHR Question 14 Which of the following is an example of trend analysis provided by an EHR? 1. An article on from a professional medical journal 2. A generic equivalent to a brand name drug 3. A graph showing a client’s cholesterol levels over time 4. A message automatically generated from the data Answer: 3 Rationale 1: An article from a professional journal is an example of decision support Rationale 2: A generic equivalent is an example of the use of a formulary in the EHR Rationale 3: Graphs of the client’s cholesterol levels, blood pressure, or temperature are examples of trend analysis Rationale 4: An alert is a message automatically generated from the data Question 15 Which of the following would the nurse not consider a benefit of client-entered data? 1. The client is an authority on the symptoms he experienced when an illness started. 2. The client can enter accurate information about her social and family history. 3. The client can review and make corrections to previous entries made by medical staff. 4. The client can comment on the success of previous treatments that were recommended by the clinic. Answer: 3 Rationale 1: The client is the authority on his or her symptoms, and is best able to accurately describe them Rationale 2: Entering demographic information in an EHR is similar to filling out the registration form in a facility or office, and an appropriate task for the client Rationale 3: The client should not be able to change information input by medical personnel; he or she should be able to review content, and discuss accuracy with the health care team Rationale 4: The client is the authority on the success of previous care Question 16 An alert that warns a provider that a brand name drug is not covered by a client’s insurance plan is an example of a(n): 1. ABN alert. 2. formulary alert. 3. nonaction alert. 4. electronic lab order system alert. Answer: 2 Rationale 1: An ABN alert is a waiver required by CMS in which the client indicates that he or she was notified in advance that a test is not going to be covered Rationale 2: A formulary alert notifies the provider that the client’s pharmacy benefits are not going to pay for a particular medication; this gives the provider the option of ordering an alternative medication Rationale 3: A nonaction alert can notify an administrator that a medical item has not been handled in a timely fashion Rationale 4: Electronic lab order systems can alert the clinician or nurse if Medicare will not cover a test, or when a blood value is outside of a certain range Question 17 Jenna has a penicillin allergy. Which of the following alerts in an EHR would detect this allergy? 1. DUR 2. PDR 3. ABN 4. HL7 Answer: 1 Rationale 1: The drug utilization review (DUR) will check allergy records, in addition to medication interactions, duplicate therapy, and other contraindications Rationale 2: The Physicians Drug Reference (PDR) is a reference resource for clinicians Rationale 3: The Advance Beneficiary Notice of Noncoverage (ABN) notifies the client if Medicare will not be paying for a particular medication or therapy Rationale 4: HL7 (Health Level 7) is a nonprofit organization and the leading messaging standard used by healthcare computer systems to exchange information; HL7 is used to translate and interface data into the main EHR Question 18 A parent receives a letter in the mail from the pediatrician that their child is due to receive certain immunizations. This is an example of which functional benefit of codified EHR data? 1. Trend analysis 2. Health maintenance 3. Alerts 4. Decision support Answer: 2 Rationale 1: Trend analysis is used when the same test is performed over a period of time, and the fielded and coded data is used to generate graphs and reports Rationale 2: Health maintenance, or preventive care systems are used to compare CDC recommended vaccines and intervals with the client’s immunization history to generate alerts Rationale 3: Alerts are messages or reminders that are automatically generated by the EHR system; alerts are based on programmed rules that cause the EHR to alert the provider Rationale 4: Decision support refers to the ability of EHR systems to store or quickly locate materials relevant to the findings of the current case; they include protocols, standard care guidelines Question 19 What is a medical protocol? 1. Treatment recommendations for the use of certain drugs 2. A standard plan of therapy established for different conditions 3. Evidence-based guidelines used for client diagnosis 4. Medication dosing guidelines based on test results Answer: 2 Rationale 1: drug formularies and electronic prescription systems provide decision support regarding medications Rationale 2: A protocol is a standard plan of therapy established for different conditions, and can speed documentation of the care plan and improve client care Rationale 3: Medical references can be accessed directly from the EHR, providing access to evidence-based guidelines for health care professionals Rationale 4: Medication dosing can be monitored using laboratory results and comparing with dosing changes, using codified date from the EHR Question 20 An insurance billing code represents a: 1. client’s symptoms. 2. nurse’s observations. 3. service that was rendered. 4. treatment plan. Answer: 3 Rationale 1: The client’s symptoms are subjective and objective findings of the client history and physical examination Rationale 2: The nurse’s observations are objective data that can be entered in the client’s history and physical exam Rationale 3: An insurance billing code represents a codified service that was rendered to the client Rationale 4: The treatment plan details can be codified, and linked with symptoms, elements of the physical exam and assessments Question 21 Which of the following are examples of digital images? Standard Text: Select all that apply. 1. scanned documents 2. diagnostic images 3. transcription notes 4. fielded data 5. coded data Answer: 1, 2 Rationale 1: Digital images include diagnostic images, such as digital x-rays, CAT scans, digital pathology, as well as scanned documents such as paper forms, old medical records or letters Rationale 2: Transcription notes are an example of text files Rationale 3: Fielded data is an example of discrete data Rationale 4: Coded data is an example of discrete data Rationale 5: Digital images include diagnostic images, such as digital x-rays, CAT scans, digital pathology, as well as scanned documents such as paper forms, old medical records or letters Question 22 The client is entering data into the EHR. What type of data does the client commonly enter? Standard Text: Select all that apply. 1. family history 2. current symptoms 3. vital signs 4. medical history 5. medications Answer: 1, 2, 4, 5 Rationale 1: The client is always the source of family history, making this appropriate data set for client-entered data Rationale 2: The client is experiencing the symptoms, and is a more accurate reflection of the symptoms Rationale 3: Vital signs are taken and entered into the EHR by the nurse Rationale 4: The client is the source of past medical history, making it an appropriate data set for client entered data Rationale 5: The client’s medication list can be entered by the client and reviewed by the nurse prior to linking the data to the EHR Question 23 The nurse is caring for a client who has a history of bleeding, and has been treated with multiple transfusions. Which of the following functional benefits will assist the nurse in evaluating the client’s progress? Standard Text: Select all that apply. 1. trend analysis 2. health maintenance 3. alerts 4. decision support 5. population health reporting Answer: 1, 3, 4 Rationale 1: The client’s laboratory results can be compared to treatment, such as transfusions, to evaluate progress Rationale 2: Health maintenance support would not apply for this scenario Rationale 3: Alerts might be generated by the EHR based on abnormal laboratory reports and medications with toxic side effects based on the client’s diagnosis or lab tests Rationale 4: The nurse or other provider might utilize a database to research treatment alternatives Rationale 5: Population health reporting would not apply for this client. Question 24 The nurse is caring for an elderly client. What types of preventive screening might be entered into the EHR to complete the client’s record? Standard Text: Select all that apply. 1. Date of last colonoscopy 2. Date of last mammogram 3. Date of last TB test 4. Date of last influenza vaccine 5. Date of last eye exam Answer: 1, 2, 3, 5 Rationale 1: Date of last colonoscopy, mammogram, TB test and eye exam are all examples of preventive care screening Rationale 2: Date of last colonoscopy, mammogram, TB test and eye exam are all examples of preventive care screening Rationale 3: Date of last colonoscopy, mammogram, TB test and eye exam are all examples of preventive care screening Rationale 4: the last influenza vaccine is an example of data to be entered into the immunization records of the client’s EHR Rationale 5: Date of last colonoscopy, mammogram, TB test and eye exam are all examples of preventive care screening Question 25 The nurse is reviewing the medication record of a client. Which of the following EHR categories will be helpful in determining potential medication interactions? 1. client entered data 2. decision support 3. health maintenance 4. trend analysis Answer: 2 Rationale 1: Client entered data may provide potential medications and supplements that will cause interactions, but will not support the nurse’s review Rationale 2: Decision support, such as prescription support of medication dosing can assist the nurse in reviewing the client’s medications Rationale 3: health maintenance support in the EHR will not assist the nurse with this review Rationale 4: Trend analysis will not be the most helpful component in the EHR for this review Question 26 The nurse understands that a codified EHR is important because: Standard Text: Select all that apply. 1. searching the EHR is faster 2. treatment identification is vague 3. clinicians findings are precise 4. data can be exchanged 5. it keeps information private Answer: 1, 3, 4 Rationale 1: codified data makes EHR searches almost instantaneous Rationale 2: Treatment is precisely identified in coded data Rationale 3: Clinicians’ findings are precisely identified in a codified EHR Rationale 4: data can be exchanged between different EHR systems or facilities, yielding better continuity of care Rationale 5: the purpose of codified data is not to keep information private or in ‘code’ Question 27 The nurse explains the purpose(s) of the drug utilization review program in the EHR as including: Standard Text: Select all that apply. 1. possible drug interactions 2. possible drug duplication 3. contraindications for current diagnosis 4. dosage guidelines 5. drug cost Answer: 1, 2, 3, 4 Rationale 1: DUR programs check the medication ordered against current medications and supplements Rationale 2: DUR programs check the medication ordered against the client’s diagnosis history to be certain the drug can be given to the client Rationale 3: DUR programs check the medication ordered against the client’s diagnosis history to be certain the drug can be given to the client Rationale 4: If the Sig has been entered at the time of the DUR, then it is checked against recommended guidelines for the drug Rationale 5: DUR does not review medication costs Question 28 The nurse identifies the following steps in cataloging images: Standard Text: Select all that apply. 1. scanning documents 2. importing images into an image system 3. identifying client allergies 4. tying image to correct client 5. identifying provider Answer: 1, 2, 4, 5 Rationale 1: The first step in cataloging images is scanning the document into the EHR Rationale 2: the second step is importing images into the appropriate image system Rationale 3: Client allergies are not part of the cataloging process Rationale 4: Tying the image to the correct client with the client ID, etc. is an important part of the cataloging process Rationale 5: Identifying the provider and type of image are part of the cataloging process Question 29 The health care team might want to import client data into the EHR from what types of devices? Standard Text: Select all that apply. 1. vital sign monitors 2. cardiac monitors 3. glucose meters 4. pedometers 5. fetal monitors Answer: 1, 2, 3, 5 Rationale 1: Importing vital signs into the EHR will allow the health care team to analyze vital sign trends Rationale 2: Importing cardiac monitor data into the EHR will allow the health care team to monitor efficacy of medication therapy Rationale 3: Importing glucose meter data will assist the health care team in monitoring the client’s progress with diabetic control, and analyze blood sugar trends Rationale 4: A pedometer data is not a biomedical device Rationale 5: Importing fetal monitor data into the mother’s EHR will all caregivers to monitor trends in fetal well being Question 30 The EHR can assist the nurse in care planning by: Standard Text: Select all that apply. 1. identifying diagnoses 2. identifying intervention standards 3. identifying medication reactions 4. identifying outcome standards 5. identifying allergies Answer: 2, 4 Rationale 1: The EHR does not identify nursing diagnoses; it may list the NANDA-I classification Rationale 2: The EHR makes it possible to quickly identify intervention standards based on the nursing diagnosis, using NIC Rationale 3: medication reaction identification is not part of nursing care planning Rationale 4: Nursing outcome standards (NOC) can be quickly identified by the EHR based on the nursing diagnosis Rationale 5: Allergy identification is not part of nursing care planning Test Bank for Electronic Health Records and Nursing Richard Gartee, Sharyl Beal 9780131383722, 9780132885522
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