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C468 Exam Study Guide
1. Information literacy: Defined as the ability to recognize when information is needed as well as the skills to find, evaluate and use needed information
ettectively
2. Information: Term used to describe data that has been interpreted
3. Information science: Focus on how to gather, process and transform information into knowledge. It also incorporates features from 5 other sciences
-communication science -computer science -social science -library science -cognitive science
4. Information systems: Using the EHR to document care of a patient with a fractured femur is an example of using the EHR in which way
5. Simulation Technology Improving patient outcomes.: Allowing them hands-on practice and immediate feedback of the skill being
learned
6. Knowledge worker: Nurses in this type of role
-are continuous learners -use technology to support and inform nursing practice -generate knowledge as a product
7. Expert/Experienced Nurse: Expected to fully integrate informatics throughout the course of his/her practice, not just for basic data entry and retrieval.
They also know how to pull trends out of data
8. Nursing informatics: Nursing informatics as a specialty does have its own National certification exam
9. Clinical practice guidelines: Clinical practice guidelines can allow for the creation of nursing policies. True rooted in evidenced based research
10. Information technologies, not systems but functions within a system: CPOE, bar code medication administration, and
clinical decision support are all examples of what
11. Computerized Physician Order Entry (CPOE): The name used to describe the process by which the physician or provider enters
orders electronically into the EHR
12. RFID: A radio frequency identifier (RFID) is a type of (information) technology that is used to identify and track supplies and medications within a
healthcare environment
13. Informatics affecting Nursing Practice: Clinical pathways and computer generated care plans are examples of how informatics can
attect nursing practice True, examples of clinical decision support
14. Nursing informatics: The use of technology and information to help support all aspects of nursing practice
15. The foundation of knowledge model: The basis for which knowledge is used to meet the needs of the healthcare delivery system
It is derived from its 3 key elements of knowledge acquisition, knowledge processing and knowledge dissemination
16. Data (not information until it has been analyzed): A patients height, weight, code status, and date of birth are all examples of
what
17. Less consumer accountability: Not an emerging trend in healthcare
18. Mission: The purpose or reason for an organizations existence
19. Strategic planning, long-range: The development of a comprehensive long range plan for guiding the activities and operations of an
organization
20. They will need to be trained on the system: Why is it not important that selection committee board members understand software and
electronic processes
35. EHR Primary Benefit: One primary benefit of the EHR is a decreased wait time for diagnostic test- ing...FALSE
36. EHR Main Goal: Primary goal of EHR functionality in contrast to that of a health information system is promoting patient safety
37. HIS Health Information System: Broad term used to describe administrative and clinical systems to streamline work flow processes
eflciency
38. Barrier to patient centered care: Is waiting until the end of the shift to chart patient assessments a barrier to patient centered care...Yes, chart in
real time. Computer position can be a barrier if it is placed between the provider and the patient...pay attention to your patient.
39. Standardization of Data and Different data needs of each clinic: What potential challenge can occur when
implementing an EHR in a medical center with various outpatient clinics
40. Local Area Network (LAN) access: What is the type of connection is needed to access the EHR when an internet connection is lost
41. EHR Information Includes: Immunization history, CT scan results, date of birth
42. EHR Quality Care Between Facilities: By providing continuity of care, interoperability
43. EHR: The EHR is a longitudinal electronic patient record of all health care encounters...carries with the patient (longitudinal)
44. Medication Administration System (Pyxis) Access: Barcode ID badge, fingerprint
45. Order entry system: Type of health information system that ensures the accuracy of physician orders
46. ADT System (Admission, discharge, transfer): A registration system is also commonly refer- eed to as
47. Health information systems: A group of systems used within the hospital to support and enhance healthcare
48. HIS Implementation Nursing: It is important to secure statt nurses active participation when im- plementing a health information system
b/c the nurses knowledge of current patient care workflow may improve implementation decisions
49. Standardized Terminologies important to nursing: They improve communication within the interdisciplinary team
50. HIS Examples: Laboratory system, pharmacy system, registration system
51. Perioperative nursing data set (PNDS): Which nursing terminology contains a nursing diagnosis, interventions and outcomes specific
to the perioperative experience
52. Standardized Terminologies in Nursing Informatics Development is Driven by what Principles:
Accessibility, ubiquity, longevity, reusability
53. Collaboration when selecting a Health Care System: Collaboration leads to knowledge sharing
54. Administrative Information System Examples: Scheduling system, financial system, admis- sion, discharge and transfer (ADT) system
55. Clinical Information Systems Examples of Effectiveness: The information retrieved can be used to foster research, improves
nursing documentation compliance, It can improve clinician workflow
56. HL7 (Health Level 7): Acronym used to refer a standard of interoperability and exchange of clinical data
57. Financial Systems are designed to do what: Manage the expenses and revenue of providing healthcare, report and track fiscal
outcomes as they relate to organizational goals, help to determine the organizations strategic direction
58. EHR implementation challenges in a medical center with various specialties-
: Identifying the ditterent data needs for each specialty practice
59. Clinical Decision Support Tool Characteristics: Takes specific patient data, analyzes it and provides recommendations (next action)
60. Clinical Decision Support Tool Examples: Computer generated care plans, alerts, smart pumps, electronic drug references
61. Culture of Safety Principles: 1. Commitment of resources
2. Cross collaboration
3. Blame free environment
62. Security Threats to data/information: 1. Unauthorized personal accessing equipment
system in multiple ways Testing - In ditterent place than being used Compatibility - With other systems
72. Computer Technology: Collection of data for analysis used to justify the eflciency of particular interven- tions & improve quality care
73. Computer Hardware: Input device, CPU, Secondary Storage, Output Device
74. ANA Terminologies: NANDA, NIC, NOC, CCC, ICNP, PNDA, Omaha System
75. ARRA (American Recovery & Reinvestment Act: Provides funds for adoption of technology and provides the right for every
individual to receive electronic copy of EHR
76. EMR Basic Components: Clinical messaging, email, data repository, clinical docum
77. CIS: Access to client data to Plan, Implement, Evaluate Care
78. Clinical Term: Enables the capture of data for patient care docum
79. Computer System: Hardware, Software, Data, Procedures, Users
80. CPOE: Needs downtime procedure or policy prior to implement
81. CPU: BRAIN, computer chip processes all computer functions and uses
82. NO integration: C-3PO and RUG's
83. EBP Attributes: Increased job satisfaction, improved quality of care
84. EBP: The use of research and evidence to inform clinical practice, an approach to provide care that integrates nursing experience and intuition with valid
and current clinical research to achieve the best PT outcomes
85. EDI Electronic Data Interchange: Permits multiple systems to acquire and share data
86. EBP Provides: Standardized best practices, reduces time nurses spend gathering and assessing data, and provide care w/ clinical research
87. EMR: Electronic version of the client data found in the traditional medical record
88. EMR Provides: Legal record often restricted to a single visit of care, building block of EHR
89. HIPPA Compliant Codes: ICD, ABC, Common Procedural Terms
90. HIPPA Provides: Legal protections for personal health info, set standards for electronic data interchange of claims data, named specific code sets for use
in Medicare related transactions and priv
91. HITECH (Health Information Technology for Economic and Clinical Health): -
Strengthened HIPPA security and privacy protection, provides financial incentive for user of EHR
92. Nurse uses Data: Accessing Information, Collecting Data, Inputting Data, Analyzing Data
93. Informatics Innovator: Process of making enhancements or improvements..creative
94. Informatics Nurse: Advance knowledge and proficiency in the use of IT as it applies to nursing practice.
95. Interfacing Types: 1. Point to Point - Enables 2 systems to communicate, expensive, has to have customized program
- Interface Engine - Interfacing across several ditterent systems.
96. Internet Security Measures: 1. Firewall - Prevents unwanted access to the system and it's information
2. Limit web page access
3. Server Security - Information stored is not accessible to other systems if they are attacked
4. Update security software
97. Intranet/Extranet: Intranet - Private networks that cannot be accessed outside the organization Extranet - Network outside the
organization that enables customers and suppliers access to the services.
100. Knowledge: The synthesis of information from several sources to produce a single concept or idea Ex. journal about BP
101. LAN: Connect a few computers to the server over a large area ex. doc's placing orders from home.
102. Needs to be Integrated: ICD-9, G-Codes, ICD-10, CPT, HCSPC
103. Network: Combination of hardware and software that allows communication & electronic transfer between computers
Connects Multiple computers in ditterent locations
104. Novice: Beginner w/ no experience with situations in which they are expected to perform a task...taught rules to guide actions
105. Nursing Informatics: Integration of nursing science, computer science, and information science to manage and communicate data, information,
knowledge, and wisdom into nursing practice.
106. Nursing Information System: Standardized nursing language (SNL) 2 approaches
1. Nursing Process Approach & Critical Pathway - Multi Disciplinary teams throughout. Physician orders are present for the team to observe and follow, allows the team to
update the POC when variances in the PT condition are noted.
2. Protocol Approach - Streamline documentation of assessment, med info, discharge info and education
107. Qualitative Research: Concerned with finding out more about the human experience, accomplished through interviews and over a long period of
time. EX How interventions could impact an entire population, content analysis, computers can code responses to questionnaires which can them be inputted in the informatics system for analysis.
108. Quantitative Research: Concerned with objectivity, tight control over situations, define relationships between variables, seek correlation between
data. EX Tries to discover how an intervention has impacted subjects IN DEPTH, tangible relations between variables.
109. EMR Adoption Stages: 0-Organization
1. All 3 key ancillary departments (lab, pharm, radiology) installed
2. CDR - Clinical Data Repository provides physician access for reviewing orders and results. Possibly HIE Capable.
3. Nursing/Clinical Documentation - EMAR, first level of clinical decision support is implemented.
4. CPOE implementation
5. Closed loop med administration w/ bar codes is implemented, 5 rights of med. administration
6. Full physician documentation, full radiology and PACS
7. No more paper charts
110. Patient Information: Standard (temp, weight), General, Targeted, Personalized (specific info on condi- tion pt has been dx with ex DII), Tailored
(Gleaned from EMR EHR focuses specifically on conditions IND Based)
111. Telemedicine: Improve pt outcomes by permitting pts to remain at home,
allows pts to communicate w/ provider about blood glucose test or video conference w/ them directly to develop pt specific education opportunities, directed by doctors
112. Telehealth Options: 1. Store & Forward- items are transferred to experts who read
and interpret information and send back results
- Real Time- interactive conferencing
113. Teleconferencing: Use of computers, audio, & video equip. and high-grade
dedicated telephone line, cable/sat connections to provide interactive communication between 2+ ppl at 2+ sites
