Chapter 15
Question 1
Which of the following terms is defined as structured and controlled languages that have been
developed according to terminology development guidelines?
1. Standardized terminologies
2. Health care standards
3. Health care terminology
4. Health information standards
Correct Answer: 1
Rationale 1:
Standardized terminologies are structured and controlled languages that have been developed
according to terminology development guidelines and have been approved by an authoritative
body (HIMSS, 2006).
Rationale 2:
Standardized terminologies are structured and controlled languages that have been developed
according to terminology development guidelines and have been approved by an authoritative
body (HIMSS, 2006).
Rationale 3:
Standardized terminologies are structured and controlled languages that have been developed
according to terminology development guidelines and have been approved by an authoritative
body (HIMSS, 2006).
Rationale 4:
Standardized terminologies are structured and controlled languages that have been developed
according to terminology development guidelines and have been approved by an authoritative
body (HIMSS, 2006).
Question 2
The use of which of the following is a means of ensuring the data collection is accurate and
valid?
1. Standardized terminology
2. Tablets
3. Bar coding
4. Handheld devices
Correct Answer: 1
Rationale 1:
The use of standardized terminology is a means of ensuring the data collection is accurate
and valid. Standardized terminology is essential for successful development and
implementation of an EHR. Terminology is required to represent, communicate, exchange,
manage, and report data, information, and knowledge. It enables safe, patient-centric, high
quality health care that optimizes data collection for the measurement of patient outcomes.
Rationale 2:
The use of standardized terminology is a means of ensuring the data collection is accurate
and valid. Standardized terminology is essential for successful development and
implementation of an EHR. Terminology is required to represent, communicate, exchange,
manage, and report data, information, and knowledge. It enables safe, patient-centric, high
quality health care that optimizes data collection for the measurement of patient outcomes.
Rationale 3:
The use of standardized terminology is a means of ensuring the data collection is accurate
and valid. Standardized terminology is essential for successful development and
implementation of an EHR. Terminology is required to represent, communicate, exchange,
manage, and report data, information, and knowledge. It enables safe, patient-centric, high
quality health care that optimizes data collection for the measurement of patient outcomes.
Rationale 4:
The use of standardized terminology is a means of ensuring the data collection is accurate
and valid. Standardized terminology is essential for successful development and
implementation of an EHR. Terminology is required to represent, communicate, exchange,
manage, and report data, information, and knowledge. It enables safe, patient-centric, high
quality health care that optimizes data collection for the measurement of patient outcomes.
Question 3
The use of standardized nursing terminology will result in better ______________________
among the interdisciplinary team.
Correct Answer: communication
Rationale: The use of coded standardized terminology for nurses is vital to bedside nursing
and to the nursing profession. It is essential because it enables consistent use of terminologies
across clinical settings and specialists. The use of standardized nursing terminology will
result in better communication to the interdisciplinary team, increase the visibility of nursing
interventions, enhance data collection used to evaluate and analyze patient care outcomes,
and support greater adherence to standards of care. Further, the use of standardized nursing
terminology can be used to assess nursing competency. Health care facilities are required to
demonstrate the competency of staff for the Joint Commission. The nursing interventions
delineated in standardized terminologies can be used as a means by which to assess nurse
competency in the performance of these interventions (Rutherford, 2008).
Question 4
The American Nurses Association established criteria for recognizing standardized
terminologies. The terminologies must meet established criteria to be approved. Which of the
following are instrumental in the approval process?
1. Outcome identification
2. Diagnosis
3. Problem solving
4. Decision making
5. Nursing process data elements
Correct Answer: 1,2,5
Rationale 1:
Terminologies must be used to support nursing practice reflecting the nursing process. The
nursing process data elements include assessment, diagnosis, outcome identification (goal),
planning, implementation (interventions), and evaluation. The terminologies have to contain
concepts that are clear and unambiguous with a unique identifier. The terminology developer
should have an outlined maintenance and submission process.
Rationale 2:
Terminologies must be used to support nursing practice reflecting the nursing process. The
nursing process data elements include assessment, diagnosis, outcome identification (goal),
planning, implementation (interventions), and evaluation. The terminologies have to contain
concepts that are clear and unambiguous with a unique identifier. The terminology developer
should have an outlined maintenance and submission process.
Rationale 3:
Terminologies must be used to support nursing practice reflecting the nursing process. The
nursing process data elements include assessment, diagnosis, outcome identification (goal),
planning, implementation (interventions), and evaluation. The terminologies have to contain
concepts that are clear and unambiguous with a unique identifier. The terminology developer
should have an outlined maintenance and submission process.
Rationale 4:
Terminologies must be used to support nursing practice reflecting the nursing process. The
nursing process data elements include assessment, diagnosis, outcome identification (goal),
planning, implementation (interventions), and evaluation. The terminologies have to contain
concepts that are clear and unambiguous with a unique identifier. The terminology developer
should have an outlined maintenance and submission process.
Rationale 5:
Terminologies must be used to support nursing practice reflecting the nursing process. The
nursing process data elements include assessment, diagnosis, outcome identification (goal),
planning, implementation (interventions), and evaluation. The terminologies have to contain
concepts that are clear and unambiguous with a unique identifier. The terminology developer
should have an outlined maintenance and submission process.
Question 5
Which of the following terminologies have been approved by the American Nurses
Association?
1. Nursing Management Minimum Data Set (NMMDS)
2. Nursing Minimum Data Set (NMDS)
3. Alternative Billing Codes (ABC Codes)
4. Clinical Care Classification (CCC)
5. North American Nursing Diagnosis International (NANDA-I)
Correct Answer: 1,2,3,4,5
Rationale 1:
The Nursing Management Minimum Data Set (NMMDS), Nursing Minimum Data Set
(NMDS), Alternative Billing Codes (ABC Codes), North American Nursing Diagnosis
International (NANDA-I), and Clinical Care Classification (CCC) are data sets approved by
the ANA.
Rationale 2:
The Nursing Management Minimum Data Set (NMMDS), Nursing Minimum Data Set
(NMDS), Alternative Billing Codes (ABC Codes), North American Nursing Diagnosis
International (NANDA-I), and Clinical Care Classification (CCC) are data sets approved by
the ANA.
Rationale 3:
The Nursing Management Minimum Data Set (NMMDS), Nursing Minimum Data Set
(NMDS), Alternative Billing Codes (ABC Codes), North American Nursing Diagnosis
International (NANDA-I), and Clinical Care Classification (CCC) are data sets approved by
the ANA.
Rationale 4:
The Nursing Management Minimum Data Set (NMMDS), Nursing Minimum Data Set
(NMDS), Alternative Billing Codes (ABC Codes), North American Nursing Diagnosis
International (NANDA-I), and Clinical Care Classification (CCC) are data sets approved by
the ANA.
Rationale 5:
The Nursing Management Minimum Data Set (NMMDS), Nursing Minimum Data Set
(NMDS), Alternative Billing Codes (ABC Codes), North American Nursing Diagnosis
International (NANDA-I), and Clinical Care Classification (CCC) are data sets approved by
the ANA.
Question 6
Which of the following is a nursing classification designed to document the six steps of the
nursing process across the care continuum?
1. International Classification of Nursing Practice (ICNP)
2. NANDA International Nursing Diagnoses
3. NANDA-I Taxonomy II
4. Clinical Care Classification (CCC) System
Correct Answer: 4
Rationale 1:
The Clinical Care Classification (CCC) System is a nursing classification designed to
document the six steps of the nursing process across the care continuum (Saba, 2007). It
facilitates patient care documentation at the point of care. CCC nursing interventions consist
of 198 categories classified into 72 major categories and 126 subcategories that represent
interventions, procedures, treatments, and activities. CCC is an open source terminology with
no license fees. The terminology tables can be freely downloaded from www.sabacare.com. It
is copyrighted and use of CCC within an EHR requires written permission.
Rationale 2:
The Clinical Care Classification (CCC) System is a nursing classification designed to
document the six steps of the nursing process across the care continuum (Saba, 2007). It
facilitates patient care documentation at the point of care. CCC nursing interventions consist
of 198 categories classified into 72 major categories and 126 subcategories that represent
interventions, procedures, treatments, and activities. CCC is an open source terminology with
no license fees. The terminology tables can be freely downloaded from www.sabacare.com. It
is copyrighted and use of CCC within an EHR requires written permission.
Rationale 3:
The Clinical Care Classification (CCC) System is a nursing classification designed to
document the six steps of the nursing process across the care continuum (Saba, 2007). It
facilitates patient care documentation at the point of care. CCC nursing interventions consist
of 198 categories classified into 72 major categories and 126 subcategories that represent
interventions, procedures, treatments, and activities. CCC is an open source terminology with
no license fees. The terminology tables can be freely downloaded from www.sabacare.com. It
is copyrighted and use of CCC within an EHR requires written permission.
Rationale 4:
The Clinical Care Classification (CCC) System is a nursing classification designed to
document the six steps of the nursing process across the care continuum (Saba, 2007). It
facilitates patient care documentation at the point of care. CCC nursing interventions consist
of 198 categories classified into 72 major categories and 126 subcategories that represent
interventions, procedures, treatments, and activities. CCC is an open source terminology with
no license fees. The terminology tables can be freely downloaded from www.sabacare.com. It
is copyrighted and use of CCC within an EHR requires written permission.
Question 7
Terminologies can be incorporated within the electronic health record (EHR) thereby
improving practice. Which of the following are considered uses for this technology in health
care?
1. Classification
2. Reference
3. Point of care
4. Coding
5. Denial of claims
Correct Answer: 2,3
Rationale 1:
Terminologies are used two different ways within EHR systems— first, as a reference
terminology and second, as a point-of-care terminology. A reference terminology consists of a
set of concepts with definitional relationships. A point-of-care terminology, frequently
referred to as an interface terminology, is what the clinicians see on the screen and consists of
terms with which clinicians are familiar.
Rationale 2:
Terminologies are used two different ways within EHR systems—first, as a reference
terminology and second, as a point-of-care terminology. A reference terminology consists of a
set of concepts with definitional relationships. A point-of-care terminology, frequently
referred to as an interface terminology, is what the clinicians see on the screen and consists of
terms with which clinicians are familiar.
Rationale 3:
Terminologies are used two different ways within EHR systems—first, as a reference
terminology and second, as a point-of-care terminology. A reference terminology consists of a
set of concepts with definitional relationships. A point-of-care terminology, frequently
referred to as an interface terminology, is what the clinicians see on the screen and consists of
terms with which clinicians are familiar.
Rationale 4:
Terminologies are used two different ways within EHR systems—first, as a reference
terminology and second, as a point-of-care terminology. A reference terminology consists of a
set of concepts with definitional relationships. A point-of-care terminology, frequently
referred to as an interface terminology, is what the clinicians see on the screen and consists of
terms with which clinicians are familiar.
Rationale 5:
Terminologies are used two different ways within EHR systems—first, as a reference
terminology and second, as a point-of-care terminology. A reference terminology consists of a
set of concepts with definitional relationships. A point-of-care terminology, frequently
referred to as an interface terminology, is what the clinicians see on the screen and consists of
terms with which clinicians are familiar.
Question 8
______________________________ is a globally recognized controlled health care
vocabulary that provides a common language for electronic health applications.
Correct Answer: SNOMED CT
Rationale: SNOMED CT is a globally recognized controlled health care vocabulary that
provides a common language for electronic health applications. SNOMED CT is SNOMED
CT enables a consistent way of capturing, sharing, and aggregating health data across
specialties and sites of care. The use of SNOMED CT within electronic health records
provides interoperable data collection that can be analyzed and used in the implementation of
evidence-based practice, decision support rules, reporting of quality measures and
administrative billing.
Question 9
The ANA has recognized the Omaha System and integrated the terminology into SNOMED
CT. Which of the following best represents the value of the Omaha System?
1. The Omaha System is a problem classification scheme.
2. The Omaha System offers outcome labels.
3. The Omaha System provides nursing diagnoses.
4. The Omaha System provides diagnoses and intervention.
Correct Answer: 1
Rationale 1:
The Omaha System is a problem classification scheme that identifies signs and symptoms,
clinical findings, intervention scheme interventions, and procedures.
Rationale 2:
The Omaha System is a problem classification scheme that identifies signs and symptoms,
clinical findings, intervention scheme interventions, and procedures. Nursing Outcomes
Classification offers outcome labels.
Rationale 3:
The Omaha System is a problem classification scheme that identifies signs and symptoms,
clinical findings, intervention scheme interventions, and procedures. NANDA International
(NANDA-I) provides nursing diagnoses.
Rationale 4:
The Omaha System is a problem classification scheme that identifies signs and symptoms,
clinical findings, intervention scheme interventions, and procedures. Clinical Care
Classification (CCC) provides diagnoses and interventions.
Question 10
During the orientation to the renal oncology unit, the head nurse demonstrated the usefulness
of the Clinical Care Classification (CCC) System. Throughout the demonstration, the head
nurse discussed the value of the system to patient care. Which of the following statements
best reflects the usefulness of CCC?
1. The Clinical Care Classification (CCC) System facilitates the collection and dissemination
of lab values.
2. The Clinical Care Classification (CCC) System offers improved outcomes.
3. The Clinical Care Classification (CCC) System facilitates patient care documentation at
the bedside.
4. The Clinical Care Classification (CCC) System discloses standardized nursing
terminologies.
Correct Answer: 3
Rationale 1:
The Clinical Care Classification (CCC) System is a nursing classification designed to
document the six steps of the nursing process across the care continuum (Saba, 2007). It
facilitates patient care documentation at the point of care.
Rationale 2:
The Clinical Care Classification (CCC) System is a nursing classification designed to
document the six steps of the nursing process across the care continuum (Saba, 2007). It
facilitates patient care documentation at the point of care.
Rationale 3:
The Clinical Care Classification (CCC) System is a nursing classification designed to
document the six steps of the nursing process across the care continuum (Saba, 2007). It
facilitates patient care documentation at the point of care.
Rationale 4:
The Clinical Care Classification (CCC) System is a nursing classification designed to
document the six steps of the nursing process across the care continuum (Saba, 2007). It
facilitates patient care documentation at the point of care.
Question 11
Which of the following can be used to document the elements of the nursing process within
the care plan?
1. The Omaha System
2. The PeriOperative Nursing Data Set
3. Personal health record
4. NANDA-I
Correct Answer: 4
Rationale 1:
NANDA-I is used to document nursing diagnoses within all settings and across the care
continuum. The coding system can be used within the EHR. NANDA-I has been linked to the
NIC interventions and NOC outcomes.
Rationale 2:
NANDA-I is used to document nursing diagnoses within all settings and across the care
continuum. The coding system can be used within the EHR. NANDA-I has been linked to the
NIC interventions and NOC outcomes.
Rationale 3:
NANDA-I is used to document nursing diagnoses within all settings and across the care
continuum. The coding system can be used within the EHR. NANDA-I has been linked to the
NIC interventions and NOC outcomes.
Rationale 4:
NANDA-I is used to document nursing diagnoses within all settings and across the care
continuum. The coding system can be used within the EHR. NANDA-I has been linked to the
NIC interventions and NOC outcomes.
Question 12
_______________________________________ is standardized classification of
interventions that describes the activities that nurses perform.
Correct Answer: The Nursing Interventions Classification (NIC)
Rationale:
The Nursing Interventions Classification (NIC) is standardized classification of interventions
that describes the activities that nurses perform. NIC is used in all care settings. An
intervention is described as “any treatment, based upon clinical judgment and knowledge,
that a nurse performs to enhance patient/client outcomes“ (The University of Iowa, 2010a).
The current NIC edition (2008) has 542 interventions (Bulechek, Butcher, & Dochterman,
2008). The interventions are grouped together by 30 classes and seven domains. Each
intervention includes a label name, a definition, a unique code, and associated nursing
activities.
Question 13
Which of the following answers depicts the use of the ANA recognized nursing
classifications to codify data?
1. The ANA recognized nursing classifications codify data used during the nursing process
such as assessments, nurse sensitive problems, interventions, and outcomes.
2. The ANA recognized nursing classifications codify data is used to support input devices.
3. The ANA recognized nursing classifications align nursing outcomes.
4. The ANA recognized nursing classifications codify data for retrieval of billing invoices.
Correct Answer: 1
Rationale 1:
The ANA recognized nursing classifications codify data used during the nursing process such
as assessments, nurse sensitive problems, interventions, and outcomes.
Rationale 2:
The ANA recognized nursing classifications codify data used during the nursing process such
as assessments, nurse sensitive problems, interventions, and outcomes.
Rationale 3:
The American Nurses Association (ANA), through the Committee for Nursing Practice
Information Infrastructure (CNPII), recognizes terminologies appropriate for use by nursing
(Warren & Bakken, 2002). Terminologies must meet defined criteria for approval. The
criteria specify that terminologies must be used to support nursing practice reflecting the
nursing process. The nursing process data elements include assessment, diagnosis, outcome
identification (goal), planning, implementation (interventions), and evaluation. The
terminologies have to contain concepts that are clear and unambiguous with a unique
identifier.
Rationale 4:
The American Nurses Association (ANA), through the Committee for Nursing Practice
Information Infrastructure (CNPII), recognizes terminologies appropriate for use by nursing
(Warren & Bakken, 2002). Terminologies must meet defined criteria for approval. The
criteria specify that terminologies must be used to support nursing practice reflecting the
nursing process. The nursing process data elements include assessment, diagnosis, outcome
identification (goal), planning, implementation (interventions), and evaluation. The
terminologies have to contain concepts that are clear and unambiguous with a unique
identifier.
Question 14
Mr. Gonzalez is scheduled to undergo a hip replacement after he slipped on an icy step.
During the preoperative phase, the nurse begins to enter the assessment findings into the
database. Which of the following standardized terminologies will the nurse most likely use?
1. The Omaha System
2. The PeriOperative Nursing Data Set (PNDS)
3. North American Nursing Diagnosis International (NANDA-I)
4. International Classification of Nursing Practice (ICNP)
Correct Answer: 2
Rationale 1:
The PeriOperative Nursing Data Set (PNDS), developed by the Association of periOperative
Registered Nurses (AORN), is a standardized perioperative nursing vocabulary that provides
nurses a clear, precise, and universal language for clinical problems and surgical treatments.
The AORN’s initial goal was to develop a unified language for nursing care that could be
systematically quantified, coded, and easily captured in a computerized format in the
perioperative setting (AORN, 2002, p. 13).
Rationale 2:
The PeriOperative Nursing Data Set (PNDS), developed by the Association of periOperative
Registered Nurses (AORN), is a standardized perioperative nursing vocabulary that provides
nurses a clear, precise, and universal language for clinical problems and surgical treatments.
The AORN’s initial goal was to develop a unified language for nursing care that could be
systematically quantified, coded, and easily captured in a computerized format in the
perioperative setting (AORN, 2002, p. 13).
Rationale 3:
The PeriOperative Nursing Data Set (PNDS), developed by the Association of periOperative
Registered Nurses (AORN), is a standardized perioperative nursing vocabulary that provides
nurses a clear, precise, and universal language for clinical problems and surgical treatments.
The AORN’s initial goal was to develop a unified language for nursing care that could be
systematically quantified, coded, and easily captured in a computerized format in the
perioperative setting (AORN, 2002, p. 13).
Rationale 4:
The PeriOperative Nursing Data Set (PNDS), developed by the Association of periOperative
Registered Nurses (AORN), is a standardized perioperative nursing vocabulary that provides
nurses a clear, precise, and universal language for clinical problems and surgical treatments.
The AORN’s initial goal was to develop a unified language for nursing care that could be
systematically quantified, coded, and easily captured in a computerized format in the
perioperative setting (AORN, 2002, p. 13).
Question 15
Clinical terminologies consist of concepts that support which of the following facets of health
care?
1. Diagnostic studies
2. History and physical examinations
3. Visit notes
4. Ancillary department information
5. Outcomes measures
Correct Answer: 1,2,3,4,5
Rationale 1:
Clinical terminology enables the capture of data at the level of detail necessary for patient
care documentation and is used to describe health conditions and health care activities
(ISO/IEC 17115, 2007). Clinical terminologies consist of concepts that support diagnostic
studies, history and physical examinations, visit notes, ancillary department information,
nursing notes, assessments, flow sheets, vital signs, and outcome measures. A clinical
terminology can be mapped to a broader classification system for administrative, regulatory,
and fiscal reporting requirements (Giannangelo, 2010, p. 3).
Rationale 2:
Clinical terminology enables the capture of data at the level of detail necessary for patient
care documentation and is used to describe health conditions and health care activities
(ISO/IEC 17115, 2007). Clinical terminologies consist of concepts that support diagnostic
studies, history and physical examinations, visit notes, ancillary department information,
nursing notes, assessments, flow sheets, vital signs, and outcome measures. A clinical
terminology can be mapped to a broader classification system for administrative, regulatory,
and fiscal reporting requirements (Giannangelo, 2010, p. 3).
Rationale 3:
Clinical terminology enables the capture of data at the level of detail necessary for patient
care documentation and is used to describe health conditions and health care activities
(ISO/IEC 17115, 2007). Clinical terminologies consist of concepts that support diagnostic
studies, history and physical examinations, visit notes, ancillary department information,
nursing notes, assessments, flow sheets, vital signs, and outcome measures. A clinical
terminology can be mapped to a broader classification system for administrative, regulatory,
and fiscal reporting requirements (Giannangelo, 2010, p. 3).
Rationale 4:
Clinical terminology enables the capture of data at the level of detail necessary for patient
care documentation and is used to describe health conditions and health care activities
(ISO/IEC 17115, 2007). Clinical terminologies consist of concepts that support diagnostic
studies, history and physical examinations, visit notes, ancillary department information,
nursing notes, assessments, flow sheets, vital signs, and outcome measures. A clinical
terminology can be mapped to a broader classification system for administrative, regulatory,
and fiscal reporting requirements (Giannangelo, 2010, p. 3).
Rationale 5:
Clinical terminology enables the capture of data at the level of detail necessary for patient
care documentation and is used to describe health conditions and health care activities
(ISO/IEC 17115, 2007). Clinical terminologies consist of concepts that support diagnostic
studies, history and physical examinations, visit notes, ancillary department information,
nursing notes, assessments, flow sheets, vital signs, and outcome measures. A clinical
terminology can be mapped to a broader classification system for administrative, regulatory,
and fiscal reporting requirements (Giannangelo, 2010, p. 3).
Question 16
A classification system is used to categorize the details of the clinical encounter. Which of the
following does a classification system not do?
1. Group data to determine costs and outcomes of treatment
2. Captures the level of detail necessary to document specific items at the point of care
3. Provides data to consumers on costs and outcomes of treatment options
4. Used in the collection and reporting of health statistics
Correct Answer: 2
Rationale 1:
A classification system is used to categorize the details of the clinical encounter. It does not
capture the level of detail necessary to document specific items at the point of care.
Classifications consist of mutually exclusive categories that can be used for specific
purposes. An example would be to group data to determine costs and outcomes of treatment.
A classification system provides data to consumers on costs and outcomes of treatment
options. They are used in the collection and reporting of health statistics. The International
Classification of Diseases (ICD), which is a classification system, does not consist of
definitions or defining relationships between terms.
Rationale 2:
A classification system does not capture the level of detail necessary to document specific
items at the point of care.
Rationale 3:
A classification system is used to categorize the details of the clinical encounter. It does not
capture the level of detail necessary to document specific items at the point of care.
Classifications consist of mutually exclusive categories that can be used for specific
purposes. An example would be to group data to determine costs and outcomes of treatment.
A classification system provides data to consumers on costs and outcomes of treatment
options. They are used in the collection and reporting of health statistics. The International
Classification of Diseases (ICD), which is a classification system, does not consist of
definitions or defining relationships between terms.
Rationale 4:
A classification system is used to categorize the details of the clinical encounter. It does not
capture the level of detail necessary to document specific items at the point of care.
Classifications consist of mutually exclusive categories that can be used for specific
purposes. An example would be to group data to determine costs and outcomes of treatment.
A classification system provides data to consumers on costs and outcomes of treatment
options. They are used in the collection and reporting of health statistics. The International
Classification of Diseases (ICD), which is a classification system, does not consist of
definitions or defining relationships between terms.
Question 17
The Omaha System has a multitude of functions. The system can store data describing
problems, symptoms, modifiers, interventions, and outcomes. One of the benefits of the
stored data is which of the following?
1. Decreasing services to elderly
2. Allowing patient input of data
3. Researching quality and effectiveness
4. Decreasing time spent with data collection
Correct Answer: 3
Rationale 1:
Researching quality and effectiveness leads to evidence-based practice models and decision
support rules. Data can be sorted and compared, and analyzed. The result is meaningful use
of data.
Rationale 2:
Researching quality and effectiveness leads to evidence-based practice models and decision
support rules. Data can be sorted and compared, and analyzed. The result is meaningful use
of data.
Rationale 3:
Researching quality and effectiveness leads to evidence-based practice models and decision
support rules. Data can be sorted and compared, and analyzed. The result is meaningful use
of data.
Rationale 4:
Researching quality and effectiveness leads to evidence-based practice models and decision
support rules. Data can be sorted and compared, and analyzed. The result is meaningful use
of data.
Question 18
The use of SNOMED CT within electronic health records has multiple benefits. Which of the
following are considered benefits of SNOMED CT?
1. Provides interoperable data collection that can be analyzed and used for evidence-based
practice models
2. Provides interoperable data collection that can be analyzed and used for decision support
rules
3. Provides interoperable data collection that can be analyzed and used in reporting quality
measures
4. Provides interoperable data collection that can be analyzed and used for medication
renewals
5. Provides interoperable data collection that can be analyzed and used for administrative
billing
Correct Answer: 1,2,3,5
Rationale 1:
The use of SNOMED CT within electronic health records provides interoperable data
collection that can be analyzed and used in the implementation of evidence-based practice,
decision support rules, reporting of quality measures, and administrative billing.
Rationale 2:
The use of SNOMED CT within electronic health records provides interoperable data
collection that can be analyzed and used in the implementation of evidence-based practice,
decision support rules, reporting of quality measures, and administrative billing.
Rationale 3:
The use of SNOMED CT within electronic health records provides interoperable data
collection that can be analyzed and used in the implementation of evidence-based practice,
decision support rules, reporting of quality measures, and administrative billing.
Rationale 4:
The use of SNOMED CT within electronic health records provides interoperable data
collection that can be analyzed and used in the implementation of evidence-based practice,
decision support rules, reporting of quality measures, and administrative billing.
Rationale 5:
The use of SNOMED CT within electronic health records provides interoperable data
collection that can be analyzed and used in the implementation of evidence-based practice,
decision support rules, reporting of quality measures, and administrative billing.
Question 19
Standard terminologies have been scientifically investigated for their effectiveness and
impact on patient care. The use of standard terminologies can, therefore, facilitate the use of
which of the following?
1. Multiple support languages
2. Consumer informatics
3. Computer literacy
4. Evidence-based practice and decision support rules
Correct Answer: 4
Rationale 1:
Standard terminologies can facilitate the collection and analysis of data. As a central
repository for data, the investigator can extrapolate and analyze data. From the analysis,
linkages can be determined and models support decisions are developed. As evidence-based
practice models are generated, clinical nursing practice and outcomes are improved. Multiple
support languages are not relevant when discussing a standardized language.
Rationale 2:
Standard terminologies can facilitate the collection and analysis of data. As a central
repository for data, the investigator can extrapolate and analyze data. From the analysis,
linkages can be determined and models support decisions are developed. As evidence-based
practice models are generated, clinical nursing practice and outcomes are improved.
Consumer informatics is not associated with standardized terminologies.
Rationale 3:
Standard terminologies can facilitate the collection and analysis of data. As a central
repository for data, the investigator can extrapolate and analyze data. From the analysis,
linkages can be determined and models support decisions are developed. As evidence-based
practice models are generated, clinical nursing practice and outcomes are improved.
Computer literacy is not associated with standardized terminologies.
Rationale 4:
Standard terminologies can facilitate the collection and analysis of data. As a central
repository for data, the investigator can extrapolate and analyze data. From the analysis,
linkages can be determined and models support decisions are developed. As evidence-based
practice models are generated, clinical nursing practice and outcomes are improved.
Question 20
The impact of standardized terminology throughout the U.S. health care system has grown
exponentially. Medicare and Medicaid have begun to offer financial incentives to health care
providers to promote adoption and meaningful use of interoperable health information
systems and a qualified health record. Which of the following statements best describes
meaningful use?
1. The goal of meaningful use is to input data in a manner that creates evidence-based
practice models.
2. The goal of meaningful use is to exchange clinical structured data in a manner that is
accurate and complete to improve patient care in a cost-efficient way.
3. The goal of meaningful use is to provide a warehouse of data that supports medication
renewal and patient teaching plans.
4. The goal of meaningful use is to offer the clinician patient care tools for improved
outcomes.
Correct Answer: 2
Rationale 1:
The goal of meaningful use is to exchange clinical structured data in a manner that it is
accurate and complete to improve patient care in a cost-efficient way. One of the primary
facets of meaningful use is the use of standardized language.
Rationale 2:
The goal of meaningful use is to exchange clinical structured data in a manner that it is
accurate and complete to improve patient care in a cost-efficient way. One of the primary
facets of meaningful use is the use of standardized language.
Rationale 3:
The goal of meaningful use is to exchange clinical structured data in a manner that it is
accurate and complete to improve patient care in a cost-efficient way. One of the primary
facets of meaningful use is the use of standardized language.
Rationale 4:
The goal of meaningful use is to exchange clinical structured data in a manner that it is
accurate and complete to improve patient care in a cost-efficient way. One of the primary
facets of meaningful use is the use of standardized language.
Question 21
Meaningful use requirements mandate the use of _________________________ for data
collection and reporting of established quality measures.
Correct Answer: standardized terminologies
Rationale:
Meaningful use is directly related to standardized health care terminologies. Meaningful use
requirements mandate the use of standardized terminologies for data collection and reporting
of established quality measures.
Question 22
In the last decade, and with the requirement to build EHRs that meet the 2009 meaningful use
criteria, the use of which type of data has expanded to include pay-for-performance
initiatives, care coordination, patient safety monitoring, and public health surveillance?
1. Patient
2. Coded
3. Embedded
4. Qualitative
Correct Answer: 2
Rationale 1:
In the last decade, and with the requirement to build EHRs that meet the 2009 meaningful use
criteria, the use of coded data has expanded to include pay-for-performance initiatives, care
coordination, patient safety monitoring, and public health surveillance. Many benefits have
yet to be realized from the point of care to research and the development of evidence based
practice. There are still hurdles that need to be jumped in order for systems to fully use
terminologies.
Rationale 2:
In the last decade, and with the requirement to build EHRs that meet the 2009 meaningful use
criteria, the use of coded data has expanded to include pay-for-performance initiatives, care
coordination, patient safety monitoring, and public health surveillance. Many benefits have
yet to be realized from the point of care to research and the development of evidence based
practice. There are still hurdles that need to be jumped in order for systems to fully use
terminologies.
Rationale 3:
In the last decade, and with the requirement to build EHRs that meet the 2009 meaningful use
criteria, the use of coded data has expanded to include pay-for-performance initiatives, care
coordination, patient safety monitoring, and public health surveillance. Many benefits have
yet to be realized from the point of care to research and the development of evidence based
practice. There are still hurdles that need to be jumped in order for systems to fully use
terminologies.
Rationale 4:
In the last decade, and with the requirement to build EHRs that meet the 2009 meaningful use
criteria, the use of coded data has expanded to include pay-for-performance initiatives, care
coordination, patient safety monitoring, and public health surveillance. Many benefits have
yet to be realized from the point of care to research and the development of evidence based
practice. There are still hurdles that need to be jumped in order for systems to fully use
terminologies.
Question 23
Implementing standardized terminology has many benefits to multiple beneficiaries. Which
of the following are benefits of standardized terminology?
1. Patients
2. Providers
3. Health care organizations
4. Health care industry
5. Informational technicians
Correct Answer: 1,2,3,4
Rationale 1:
Beneficiaries include the patient, the provider, the organization, and the health care industry
in general. Using standardized terminologies ensures compliance with standards coming forth
for meaningful use, quality measures, and interoperability. Terminology facilitates the
monitoring of trends and problems of the health of populations, developing clinical decision
support, and expanding our knowledge of diseases and treatments and outcomes through
research and clinical data mining.
Rationale 2:
Beneficiaries include the patient, the provider, the organization, and the health care industry
in general. Using standardized terminologies ensures compliance with standards coming forth
for meaningful use, quality measures, and interoperability. Terminology facilitates the
monitoring of trends and problems of the health of populations, developing clinical decision
support, and expanding our knowledge of diseases and treatments and outcomes through
research and clinical data mining.
Rationale 3:
Beneficiaries include the patient, the provider, the organization, and the health care industry
in general. Using standardized terminologies ensures compliance with standards coming forth
for meaningful use, quality measures, and interoperability. Terminology facilitates the
monitoring of trends and problems of the health of populations, developing clinical decision
support, and expanding our knowledge of diseases and treatments and outcomes through
research and clinical data mining.
Rationale 4:
Beneficiaries include the patient, the provider, the organization, and the health care industry
in general. Using standardized terminologies ensures compliance with standards coming forth
for meaningful use, quality measures, and interoperability. Terminology facilitates the
monitoring of trends and problems of the health of populations, developing clinical decision
support, and expanding our knowledge of diseases and treatments and outcomes through
research and clinical data mining.
Rationale 5:
Beneficiaries include the patient, the provider, the organization, and the health care industry
in general. Using standardized terminologies ensures compliance with standards coming forth
for meaningful use, quality measures, and interoperability. Terminology facilitates the
monitoring of trends and problems of the health of populations, developing clinical decision
support, and expanding our knowledge of diseases and treatments and outcomes through
research and clinical data mining.
Question 24
Multiple benefits have emerged from the use of structured terminologies within health care
records. Which of the following are considered benefits of the health information technology
(HIT)?
1. Accurate, consistent meaning of data is collected and shared across the health care system.
2. A plethora of data can be entered into the system manually.
3. Clinical terminology enables the capture of data at the level of detail necessary for patient
care documentation.
4. Standardization in nursing documentation supports research across settings on patient
outcomes and interoperability.
5. Patient identification and outcomes are clearly shared throughout the systems.
Correct Answer: 1,3,4
Rationale 1:
Structured terminologies ensure that data is collected and shared with accurate and consistent
meaning across the health care system. This enhances communication among healthcare
providers, reduces errors, and improves the quality of care.
Rationale 2:
This statement is incorrect. While health information technology may allow for the entry of a
large amount of data, the focus is not on the quantity of data entered manually but rather on
the quality and standardization of the data to ensure accuracy and consistency.
Rationale 3:
Clinical terminology enables the capture of data at a granular level, which is essential for
patient care documentation. It allows healthcare providers to accurately record patient
information, interventions, and outcomes, leading to improved patient care and decisionmaking.
Rationale 4:
Standardization in nursing documentation, facilitated by structured terminologies, supports
research across different healthcare settings by providing consistent data for analysis. This
standardization also promotes interoperability, allowing for the exchange of health
information between different systems and organizations.
Rationale 5:
While structured terminologies and HIT systems may facilitate the sharing of patient
identification and outcomes, this statement is not explicitly mentioned as a primary benefit in
the context of the question. The primary focus of structured terminologies is on standardizing
data collection and improving documentation for patient care and research purposes.
Question 25
___________________________ facilitates the monitoring of trends and problems of the
health of populations, developing clinical decision support, and expanding our knowledge of
diseases and treatments and outcomes through research and clinical data mining.
Correct Answer: Terminology
Rationale:
Implementing standardized terminology has many benefits to multiple beneficiaries.
Beneficiaries include the patient, the provider, the organization, and the health care industry
in general. Using standardized terminologies ensures compliance with standards coming forth
for “meaningful use”, quality measures, and interoperability.
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
