Ethical Decision-Making and Health Information Technology, Exams of Nursing

Download Ethical Decision-Making and Health Information Technology and more Exams Nursing in PDF only on Docsity! 1 / 11 NR599 Final Exam Study Guide Questions With Complete Solutions 1.Ethical Decision Making: -Process that requires striking a balance between science and morality -Making informed choices about ethical dilemmas based on a set of standards differentiating right from wrong. 2.Ethical Decision Making Process: 1. Identify the ethical dilemma 2.Discover alternative actions 3.Decide who might be affected 4.List the probable effects of the alternatives 5.Select the best alternative 3.Rational justification: developed through a logical process of decision making that gives proper attention to such things as facts, alternative perspectives, conse- quences to all stakeholders, and ethical principles. 4.American Nurses Association- Code of Ethics for Nurses with Interpretive Statements.: provides specific guidance for ethical decision making and provides a valuable framework that can be used when working with HIT 5. issues having an ethical component includes the following: 1. Failure to adopt technology or use it adeptly 2.Lack of regard for data integrity such as discrepancies. in record information that are noted 2 / 11 but no corrective action is taken. 3.Failure to address threats to privacy and personal health information. 4. Inappropriate access of PHI without a need to know. 5.Failure to keep informed of emerging developments and issues. 6.Failure to recognize and use technology to advance the profession. 7.Failure to engage in policy discussion that impact healthcare delivery. 8.Failure to recall that the patient is their primary focus. 9.Failure to actively participate in the selection use, and/or evaluation of technology that has the potential to improve healthcare. 6.ANAs Code of Ethics for Nurses: 1. Respect for human dignity 2.Respect for individual right to self-determinism 3.Primary commitment is to the patient (individual, family, group or community) 4.Advocacy for the patient 5.Participation in the creation, maintenance, and improvement of healthcare envi- ronments 6.Advancing the Profession 7.Collaboration with others to meet health needs 8.Shaping social policy. 7.6 contemporary Bioethical Standards: Autonomy freedom veracity privacy 5 / 11 action CDS - guide clinicians to make choices, require clinician involvement 26.What is the ICD10?: alphanumeric coding for medical diagnosis / grouping like disease provides payer info on the necessity of the visit/procedure shorthand for dx 27.What is a CPT code?: Current Procedural Technology (CPT) code represent treatments and procedures performed by a physician in a 5-digit format. for billing and reimbursement 28.6 sections of cpt coding: evaluation and management anesthesiology surgery radiology pathology medicine 29.ICD 10 is maintained by: world health org 30.CPT coding is maintained by: Am med association 31.what is LOINC: Logical Observation Identifiers, Names and Codes LOINC. , provides names and codes for laboratory test results and other observations. 32. What is SNOMED CT?: SNOMED CT or SNOMED Clinical Terms is a systemat- ically organized computer processable collection of medical terms providing codes, terms, synonyms, and definitions used in clinical documentation and reporting. 6 / 11 33.what is the purpose of SNOMED and LIONC: vocabulary used in more ad- vanced / detailed coding systems 34.Diagnosis-related groups (DRGs): System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay 35.CPT is a DRG (diagnosis related group) or MDC (major diagnosis codes)- : DRG - DRGs are more commonly associated with payment and reimbursement 36.Major Diagnosis Category (MDC): organize diagnosis that relate to similar physiological systems 37.computer aided translators: using technology to translate language or coding 38.Evaluation and Management (E/M Codes): these are listed 1st in the CPT manual b/c they are used by all different specialties. they cover physician services that are performed to determine the best course for pt care. they are a category of CPT codes used for reimbursement 39.who determines whether a mobile application is regulated for medical use: FDA 40.are mobile apps intended to provide access to electronic copies of med- ical textbooks with generic text search capabilities considered a medical devices?: No recuasse they are reference materials and not tools for dx of disease or condition 41.are mobile apps that are intended for healthcare providers to use as educational tools for medical training a medical device?: No, they are intended for general user education and not for dx 7 / 11 42.medical devices: Any equipment, instrument, implant, material, or apparatus used for the diagnosis, treatment, or monitoring of patients. 43.what makes a medical app not a medical device: Apps that are not intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease. 44.Privacy: Practice of maintaining the security and confidentiality of patient records. 45.Confidentiality: The act of holding information in confidence, not to be released to unauthorized individuals. 46.cybersecurity: -Measures taken to protect a computer or computer system against unauthorized access or attack 47.APN role in cybersecurity: determine if appropriate safeguards to protect phi are in place and if HIPPA requirements are met 48.Who is the main regulatory agency of cybersecurity: FDA 49.examples of mobile apps that the FDA intends to enforce discretion on: - apps that provide or facilitate supplemental clinical care, by coaching or prompting apps that provide patients with simple tools to organize and track their health information apps that provide easy access to information related to patients' health conditions or treatments apps marketed to help patients document, show, or communicate to providers potential medical conditions apps that perform simple calculations routinely used in clinical practice apps that enable individuals to interact with PHR systems or EHR apps that meet the 10 / 11 66.Medical Decision Making (MDM): Health care management process done after performing a history and physical examination on a patient that results in a plan of treatment. It is based on establishing one or more diagnosis and/or selecting a management or treatment option, amount of data or complexity of data reviewed, and complication and/or morbidity or mortality 67.3 key elements to medical decision making: risk data dx 68.eimbursement Coding: -Claims and documentation filed by providers using medical diagnosis and procedure codes. -Assigned contingent upon data input from clinical team members based on a summative review of the clinical record by trained coders. 69.DRG vs MDC: DRG- facilitates payment through prospective payment system MDC-organizes dx that affect similar physiological systems both primary purpose for billing 70.medical billing: process of submitting claims to receive payment 71.medical coding: codes to communicate procedures performed and why 72.each billing claim must contain what two things: A CPT (procedural)code and ICD-10 (dx) code 73.Why do you need a cpt and an ICD code: to determine reimbursement. if dx does not explain need for the procedure there is no payment 74.how many levels of care are there for e/m coding and what are they: 5 Minimal/RN visit 11 / 11 Problem focused exp problem focused detailed comprehensive 75.E/m coding for each level of a new patient: Minimal/RN visit- 99201 Problem focused- 99202 exp problem focused- 99203 detailed- 99204 comprehensive- 99205 76.E/m coding for each level of an established patient: Minimal/RN visit-99211 Problem focused- 99212 exp problem focused-99213 detailed-99214 comprehensive- 99215