NR 599 Final Exam / NR599 Final Exam (LATEST,2024): Chamberlain College of Nursing (Updat, Quizzes of Nursing

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NR 599 Final Exam / NR599 Final Exam (LATEST, 2024 ):

Chamberlain College of Nursing (Updated

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Part I: Multiple Choice Questions

1. Why is it difficult to integrate information from all hospital departments into a single hospital information system? a. Individual departments want to obtain & maintain specialized systems b. Hospital departments are organized along vertical lines while the continuum of care for patients flows along horizontal lines c. Patient care systems & financial management systems are incompatible with each other d. Each department is required by law & the Joint Commission on Accreditation of Hospitals & Health Care Organizations to maintain specific information for billing & accreditation purposes e. Individual departments do not see the value in comprehensive patient records f. Ethical Decision Making - Answer- - 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. Which of the following groups of activities represent challenges to the technologist when building an integrated hospital information system? a. Synthesizing different types of information into a cohesive whole, getting all departments to agree to a single billing procedure, realigning traditional departments into a case management model b. Synthesizing different types of information into a cohesive whole, getting all departments to agree to a single care model, realigning traditional departments into a case management model c. Allowing specific departments to retain their individualized information systems, getting all departments to agree to a single billing procedure, realigning traditional departments into a case management model d. Synthesizing different types of information into a cohesive whole, getting all departments to agree to a single billing procedure, keeping all hospital departments within the traditional vertical structure

e. Allowing all departments to retain their individual information systems, allowing all departments to have their own billing system, keeping all hospital departments separate but equal Ethical Decision Making Process - Answer- 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. The conceptual components of informatics are: a. Management, processing, & transformation b. Data, information, & paradigms c. Data, information, & knowledge d. Management, processing, & data e. Management, processing, & knowledge
6. Several colleges have suggested that Wikipedia™ be banned as a resource for academic papers. Which of the following statements support that ban? a. Wikipedia™ cannot be considered a primary source of information b. Wikipedia™ cannot be considered an authoritative source of information c. Wikipedia™ is sometimes unreliable d. Wikipedia™ allows almost anyone to edit most of its articles e. All of the above Rational justification - Answer- developed through a logical process of decision making that gives proper attention to such things as facts, alternative perspectives, consequences to all stakeholders, and ethical principles. American Nurses Association- Code of Ethics for Nurses with Interpretive Statements. - Answer- provides specific guidance for ethical decision making and provides a valuable framework that can be used when working with HIT Example of virtue ethics approach - Answer- If a manager develops good character traits and learns to overcome negative traits, he or she will make ethical decisions based on personal virtue Telehealth - Answer- use of technology to deliver health care, health information, or health education (i.e. telephone, videophone, computer, store and forward imaging, streaming media, terrestrial and wireless communications)

5. When would you use the word “and” in a literature search? a. When you want to eliminate citations with a certain term in the title b. When only one of multiple search terms must be in the title of the citation c. When all of multiple search terms must be in the title of the citation d. When you want to index a particular article e. When you want the abstract of the citations to be included in the literature search
6. What is a refereed journal? a. Any scholarly journal b. Any journal with a title that begins with “The Journal of…” c. A journal that uses a blind review process to determine the suitability and worth of articles received for publication d. Any journal that can be found on Ohio Link or through Kelvin Smith Library e. Any journal edited by someone with a Ph.D.
7. Several indexes to scholarly literature can be found in the library. Which one of these indexes has the most applicability to the profession of Nursing? a. MEDLARS b. MEDLINE c. ERIC d. CINAHL e. Social SciSearch telemedicine - Answer- medical information exchange from one site to another via electronic communications to improve patients health status Telehealth tools - Answer- Central stations, web servers, and portals Peripheral biometric(medical) devices telephones videocameras personal emergency response systems sensor and activity monitoring medication management devices special needs telecommunications ready devices(preprogrammed infusion pumps, peak flow meters)

8. Why are informatics nurse specialists and nurse scholars so interested in nursing nomenclatures, taxonomies, and classification? a. It gives them something to do b. The information is used to capture, store, and manipulate data in electronic health records c. It enhances the credibility of the profession d. It allows nurses to clearly define the profession for physicians e. All of the above
9. How many classification systems are recognized by the American Nurses Association? a. Six b. Four c. Thirteen d. Seven e. None
10. Which three data sets must be used together to complete the nursing process? a. NANDA, Clinical Care Classification (CCC), International Classification of Nursing Practice (ICNP) b. NANDA, Nursing Intervention Classification, Patient Care Data Set c. NANDA, Nursing Outcome Classification, SNOMED RT d. NANDA, Nursing Intervention Classification, Nursing Outcome Classification e. NANDA, Omaha System, SNOMED RT
11. Which of the following are forces that impact the nursing profession and are causing a growing interest in information technology? a. Change from a retrospective to a prospective reimbursement system b. Changing standards of health care accreditation agencies c. Transformation of the health care system from a provider-driven monopoly to a customer-centered, market driven, health oriented marketplace d. Shifting emphasis on automation for its own sake to data collection for survival & improvement e. All of the above Telemedicine applications types (2) - Answer- Store-and-forward or asynchronous real-time or synchronous Store and forward or asynchronous applications - Answer- exchange prerecorded data between 2 or more individuals at different times real time or synchronous applications - Answer- all involved individuals are present for immediate exchange of information

issues having an ethical component includes the following - Answer- 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 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. ANAs Code of Ethics for Nurses - Answer- 1. Respect for human dignity
10. Respect for individual right to self-determinism
11. Primary commitment is to the patient (individual, family, group or community)
12. Advocacy for the patient
13. Participation in the creation, maintenance, and improvement of healthcare environments
14. Advancing the Profession
15. Collaboration with others to meet health needs
16. Shaping social policy. 6 contemporary Bioethical Standards - Answer- Autonomy freedom veracity privacy beneficence fidelity

12. Which of the following statements is a definition of Nursing Informatics? a. Collected information technologies concerned with medical patient care & decision making b. Use of information technology management concepts & methods to support the delivery of patient care c. Complex processing of data by a computer to produce new kinds of information d. Any use of information technology by nurses in relation to the care of patients, administration of health care facilities, & educational preparation of individuals to practice nursing e. Combination of computer science, information science, & nursing science designed to assist in the management & processing of nursing data
13. The functional components of informatics are: a. Data, information, & knowledge b. Management, processing, & transformation c. Management, processing, & information d. Processing, transformation & knowledge e. None of the above
14. The role of the Informatics Nurse Specialist (INS) encompasses multiple activities ranging from the development of Informatics theory to the ongoing maintenance &provision of enhancements to information systems. Which of the following statements describes the education, experience, & user groups that concern an INS? a. Formal education & practical experience in using computers; supports the automation needs of critical care nurses b. Formal education & practical experience in using computers; supports the automation needs of maternal-child nurses c. Formal education & practical experience in using computers; supports the automation needs of community health nurses d. Formal education & practical experience in using computers; supports the automation needs of all e. Formal education & practical experience in using computers; supports the automation needs of psychiatric nurses
15. Security can be defined as: a. The right of individuals to determine at what time, in what way, & to what extent information about them is communicated to others b. Physical protection of information from unauthorized access, modification, & destruction c. An expectation that information collected will be used for the purpose for which it was gathered d. Organizational beliefs about who generates, stores, retrieves & uses information e. The belief that the existence, purpose, & type of records in system shall be public knowledge

16. Beliefs about who generates, stores, retrieves, & uses information within an organization are known as the organizations: a. Mission for information use b. Philosophy of information use c. Vision of information use d. Framework for information technology development and implementation e. Legal-ethical responsibilities for information use and storage
17. Privacy can be defined as: a. An expectation that information collected will be used for the purpose for which it was gathered b. The right of individuals to determine at what time, in what way, & to what extent information about them is communicated to others c. Protection of information from unauthorized access, modification, & destruction d. Organizational beliefs about who generates, stores, retrieves & uses information e. All of the above
18. Confidentiality can be defined as: a. Organizational beliefs about who generates, stores, retrieves & uses information b. Physical protection of information from unauthorized access, modification, & destruction c. An expectation that information collected will be used for the purpose for which it was gathered d. The right of individuals to determine at what time, in what way, & to what extent information about them is communicated to others e. The belief that the existence, purpose, & type of records in system shall be public knowledge What is the Husted bioethical decision making model centered on - Answer- healthcare professionals implicit agreement with the patient Virtue Ethics Approach - Answer- moral behavior stems from personal virtues Health - Answer- generation, aggregation, and dissemination of health info via mobile and wireless devices How can mHealth wearable devices reduce mortality rates - Answer- wrist monitors that can monitor vital signs including respiratory rate, bp, hr, spo2, and temp which can send the info to an EHR which can calculate a wellness index based on the stats and a 0-5 scale (below 2.9 is good but above 3.0 is potentially bad)

action / execution of tasks in a sequence is what - Answer- workflow

19. As a nurse practitioner, you are questioned by a patient about the usefulness of a particular web site for health information. You do not know the web site and have no computer available to access the site in your office. Which of the following replies would be the most appropriate to make to your patient? a. “If the site showed up on your search engine- it must be good. Go ahead and use it!” b. “I don’t really know the site, but here are some things to look for. You can also go to the Health on the Net Foundation and check it out” c. “Have any of your friends used it? What did they think?” d. “No Internet sites have any useful information. Let me give you some written information instead.” e. “What does your doctor think about the site?”
20. Why are nurses’ natural advocates of consumer health applications? a. With the nursing shortage, it lightens the workload b. Nurses are more computer literate than physicians c. Nurses have always taken a leadership role in patient education d. Only nurses are exposed to consumer informatics in school e. It’s easier to get patients to teach themselves than it is to spend the time and teach them
21. A consumer health care application can be described as: a. An intervention providing health care information through technology b. An outcome resulting in patient education c. A care plan detailing the steps in teaching the patient d. A patient’s application to be accepted into an insurance plan e. All of the above
22. The four areas in which Informatics Nurse Specialists practice are: a. Critical care units, neonatal intensive care units, medical-surgical units, pediatric units b. Administration, education, research, clinical practice c. Nursing science, information science, research, computer science d. Hospitals, nursing homes, outpatient clinics, mobile radiology units e. Long term care facilities, nursing homes, nursing administration offices, pediatric intensive care units observation and documentation of workflow and how it can be altered is - Answer- workflow or process analysis how is workflow analysis usually depicted - Answer- visually , in a process map

23. Which of the following are impediments to the successful implementation of a computerized medical record? a. Oversimplification of user needs b. Oversimplification of the requirements for a new system c. Little understanding of the manual system that the computerized system will be replacing d. Clinicians are not aware of what computerized medical records can and cannot do e. All of the above
24. Which of the following statements represent conditions recommended by the Institute of Medicine for the future electronic health record? a. Users must be confident that the information they have entered will integrate data from all sources reliably b. Clinicians must actively use the record in the clinical process c. Clinicians must understand that the record is a resource for use beyond patient care d. Users must be proficient in the use of information systems in health service organizations e. All of the above
25. Inputs in geographic information systems are frequently derived from: a. Hard copy maps b. Aerial photographs c. Reports & survey documents d. Human input of information e. All of the above what is it called if workflow analysis is performed AFTER a new technology is implemented - Answer- optimization Maya, autodesk and Promodel are examples of - Answer- workplace analysis process mapping tools
26. Which of the following definitions best describes a Geographic Information System? a. A computer mapping & analysis system that allows large quantities of information to be viewed & analyzed within a geographic context b. A system which allows researchers to study the distribution of disease in a neighborhood c. System which allows the community health nurse to locate a patient’s home without using a map (a Global Positioning System) d. A system which allows research about infant mortality in a particular census tract e. All of the above

27. Which of the following are limitations of Geographic Information Systems? a. Costs are often prohibitive b. Software packages are difficult to learn c. Data from government databases may not be compatible with the GIS being used for research d. None of the above e. All of the above
28. Which of the following statements justifies the need for and use of standardized nursinglanguages? a. They provide a legal record of patient care b. They support clinical decision making c. They help accumulate information to expand nursing science d. They help exchange data with internal and external systems for research e. All of the above
29. Which of the following are characteristics of a POC (point-of-care) information system? a. Supports care delivery processes b. Device for input & output of information is at the point of care c. POC system is interfaced or integrated with other hospital systems d. All of the above e. None of the above
30. Which of the following statements reflect goals that health care facilities might consider when moving to a POC system? a. Collect data at the source & present it where & when it is needed b. Minimize documentation time & eliminate redundancies & inaccuracies in charting c. Improve timeliness of documentation d. Optimize information access e. All of the above
31. Which of the following pairs of items are examples of quantitative benefits of point of care (POC) systems? a. Cost avoidance & revenue increases b. Improved process & improved patient outcomes c. Improved patient data & direct savings d. Improved patient outcomes & direct savings e. Potential savings & improved patient satisfaction

32. Which of the following pairs of items are examples of qualitative benefits of point of care (POC) systems? a. Improved process & improved patient outcomes b. Cost avoidance & potential savings c. Improved process & cost avoidance d. Improved patient outcomes & improved patient data e. Revenue increases & improved patient data 33. To be able to effectively implement a point-of care system, you need all of the following except: a. Clear goals & objectives b. A prototype system as a model c. Integration with other departments within the institution d. A team approach to system development
33. In moving a Hospital towards a POC system, multiple problems may emerge. Which of the statements listed below best describes a problem that may impact the entire institution? a. Software is not clinician friendly b. Some desired features may not be available in the chosen system c. Full sized terminals at the bedside may cause space and ergonomic (human factors) problems d. Existing computer system infrastructure may not be able to handle the additional workload of the new computers
34. Which of the following groups of items best represent the characteristics of a point of care system? a. Support of care delivery processes, terminals at the central nurse station, automated data entry & retrieval, integration with other information systems b. Support of care delivery processes, terminals at the central nurse station, manual data entry & retrieval, integration with other information systems c. Support of care delivery processes, terminals at the bedside or point of care, automated data entry & retrieval, integration with other information systems d. Support of care delivery processes, terminals at the bedside or point of care, manual data entry & retrieval, integration with other information systems e. Computer applications designed to facilitate human decision-making processes. Usually are rule based, using a specified knowledge base and a set of rules to analyze data and information and provide recommendations to users ---- what is this - Answer- clinical decision support system / CDS or CDSS what is the difference between expert systems and CDS systems - Answer- expert - not really used right now, systems that generate information / automatically intervene without requiring human action

36. Which of the following situations represent drawbacks to implementing a POC system? a. Expensive to buy, customize, & install b. Status quo of organization is disturbed c. Change in organization is required for implementation to proceed smoothly d. Software may not be clinician friendly e. All of the above
37. A nursing diagnosis is best described by which of the following statements? a. A measurable patient condition or perception resulting from one or more nursing interventions b. A taxonomy of nurse-sensitive patient outcomes c. Any direct care treatment that a nurse performs on behalf of a client d. A clinical judgment about an individual, family or community’s responses to actual or potential health problems and life processes e. Assessment activities to identify nursing diagnosis & gather data for physician identification of a medical diagnosis
38. In which stage of the five level patient record would information from alternative forms of health care be included? a. Electronic patient record b. Automated medical record c. Provider base electronic medical record d. Computerized medical record e. Electronic health record CDS - guide clinicians to make choices, require clinician involvement What is the ICD10? - Answer- alphanumeric coding for medical diagnosis / grouping like disease provides payer info on the necessity of the visit/procedure shorthand for dx What is a CPT code? - Answer- Current Procedural Technology (CPT) code represent treatments and procedures performed by a physician in a 5-digit format. for billing and reimbursement

39. Why is there an absence of nursing data in national and regional databases? a. The profession cannot agree upon & offer a set of clearly defined, reliable & standardized data elements b. The profession’s diversity does not require standardization of data c. The data collected by Nursing is not useful to Third Party Payers & does not need to be collected d. The existence of a standardized Nursing language makes this unnecessary
40. Which of the following statements best describes why the Nursing intervention classification (NIC) is important to Nursing Informatics? a. Each NIC intervention has a unique number which allows computerization of the information b. Each NIC intervention has been linked with a nursing diagnosis & with an Omaha system problem c. Each NIC intervention has been linked with a specific NOC d. Each NIC intervention is part of a comprehensive, standardized language specific to the practice of nursing
41. Heuristics can be defined as the study of: a. Holographic images b. Rules of thumb based on a person’s past experiences c. The use of natural language in robots d. Computer chips that give sight & hearing to robot
42. The thirteen data sets approved by the American Nurses Association include which of the following lists? a. SNOMED RT, NANDA, NIC, NOC, International Classification of Disease- 10 (ICD-10) b. Omaha System, NIC, NOC, International Classification for Nursing Practice, Common Procedural Terminology (CPT Codes) c. Perioperative Data Set, Nursing Management Minimum Data Set, NIC, NOC, Omaha System d. SNOMED RT, International Classification of Disease-10 (ICD-10), Common Procedural Terminology (CPT Codes), International Classification for Nursing Practice, ABC Code by Alternative Link Practice 6 sections of cpt coding - Answer- evaluation and management anesthesiology surgery radiology pathology medicine

43. Knowledge can be defined as: a. Discrete entities described objectively b. Discrete entities described without interpretation c. Information that has been synthesized d. Data that are interpreted e. Data that are organized
44. Knowledge can be transformed into which of the following a. New knowledge b. Decisions c. Discoveries d. Wisdom e. All of the above
45. The information resources of a hospital are: a. Hardware & software b. Data c. Models to organize the data d. Methods to interpret the data e. All of the above
46. Healthcare computing in hospitals began in the 1980’s and continues to the present. Which of the following activities represents the first efforts (in the 1980’s) toward computerization of healthcare? a. Knowledge creation b. Automation c. Info-mation d. Communication & Integration
47. The older terminologies of health care computing have been replaced with more meaningful, descriptive terminologies that reflect the movement toward information as a resource. To this end, data entry is now known as : : a. Decision support b. Data extraction c. Safety & Outcomes Measurement d. Knowledge acquisition e. Data mining ICD 10 is maintained by - Answer- world health org CPT coding is maintained by - Answer- Am med association what is LOINC - Answer- Logical Observation Identifiers, Names and Codes LOINC. , provides names and codes for laboratory test results and other observations.

48. The information silos of old hospital systems are now called: a. Consumer resources b. Integrated networks c. Transdisciplinary outcomes d. Decision support systems e. Knowledge repositories Part II: True/False Questions
49. Access to patient-specific, agency-specific, & domain-specific data, information & knowledge, by nurses, has potential to improve ICU decision making a. True b. False
50. The management of information is the functional ability to collect, aggregate, organize, move & represent information in an economical, efficient way. a. True b. False
51. The traditional view of information in the health care environment has been focused on the patient. a. True b. False
52. About 100 people in the US die each day because current paper base health care system introduces errors or delays treatment or limits what health care professionals know a. True b. False
53. Geographic Information Systems have been used in some form since the 1960’s. a. True b. False
54. Comprehensive patient care systems that effectively automate the medical record are not ready for implementation a. True b. False
55. The Continuity of Care Record (CCR) is intended to foster & improve continuity of patient care, to reduce medical errors, & to assure at least a minimum standard of health information transportability when a patient is referred or transferred to, or is otherwise seen by, another provider. a. True b. False

56. It is intrinsically necessary to understand how a system will be used and who will use it. What follows is that the system users must have a voice in the development, design, and use. a. True b. False
57. An organizations’ philosophy of information use provides framework for development of security policies, procedures & practices within organization a. True b. False
58. Nursing Informatics has been designated as an area of specialty nursing practice by the American Nurses Association. a. True b. False
59. A hospital database should contain data that facilitates analysis of traditional management questions relating to employees, salaries, & productivity. a. True b. False
60. A hospital database should contain data necessary to analyze work of clinical departments. a. True b. False
61. A hospital database which integrates data from several computer systems within the institution can directly support patient care. a. True b. False
62. Hospital databases should provide access to patient records for clinical research purposes. a. True b. False
63. New information needs of hospitals must include information that analyzes the cost of patient care & its interdependency with the quality of care. a. True b. False
64. Hospital Information Systems make it possible to collect & store large amounts of data beyond

the institution's immediate needs. a. True b. False

65. The traditional view of information in the health care environment has been focused on the patient. a. True b. False
66. Clinical, empirical, & conceptual knowledge are essential components in the development of a discrete Nursing language. a. True b. False
67. The Health on the Net Foundation helps patients to evaluate health related web sites. a. True b. False
68. The professional and/or contractual duty to safeguard the secrecy of patient information regardless of how it is acquired, stored, processed, generated, retrieved,or transmitted is known as confidentiality. a. True b. False
69. Early hospital information systems were primarily used for non patient care procedures such as billing, payroll, & personnel. a. True b. False
70. Consumer health informatics can best be described as tools that empower the patient to make more informed choices about healthcare issues. a. True b. False Part III: Essay Pick ONE of the following questions and answer it directly on the exam. (5 points)
71. Describe one of the VR simulations used in treating phobias.
72. It has been said that the promise of nanotechnology is to “allow doctors to execute curative & reconstructive procedures in the body at cellular & molecular levels. Discuss your concerns & opinions on the use of nanotechnology in medicine. What do you think are the ethical, legal, & moral dilemmas involved in developing & using this new technology? If you could extend life

through the use of this technology, would you? Why or why not?

3. We know that nursing unit activities represent the core of patient care in the hospital. Discuss why nurses have been reluctant to become involved in the development and implementation of information systems in health care.
4. Nursing and technology frequently clash in the clinical practice area. Nurses rightly (or wrongly) think that technology interferes with their care of patients and that “high tech” means “high touch” is absent from care. Do you think this is true? Do nurses who are able to use technology (and do) sacrifice their ability to care for patients?
5. Discuss the potential uses of Geographic Information Systems in community health, epidemiology, public health, and hospital administration. Consider such topics as the aging population, distribution of health care, distribution of care services, and development of nursing knowledge. . Arachnophobia is a phobia of spiders. Virtual reality is used to treat because it is more controlled and cost less than having an actual spider to treat patients. A patient puts on the VR helmet and glasses and wears a glove while a 3D spider movers across the screen. The spider gets closer and closer and can walk up the patient’s arm. Virtual reality is used to treat phobias such as acrophobia and arachnophobia, along with eating disorders. Virtual reality is good therapy for people with phobias because it safely elicits fear and the encounter can be controlled. It is also good because patients are more likely to want to be involved in VR therapy because it is not real and are interested in the technology. What is SNOMED CT? - Answer- SNOMED CT or SNOMED Clinical Terms is a systematically organized computer processable collection of medical terms providing codes, terms, synonyms, and definitions used in clinical documentation and reporting. what is the purpose of SNOMED and LIONC - Answer- vocabulary used in more advanced / detailed coding systems Diagnosis-related groups (DRGs) - Answer- 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 CPT is a DRG (diagnosis related group) or MDC (major diagnosis codes) - Answer- DRG - DRGs are more commonly associated with payment and reimbursement Major Diagnosis Category (MDC) - Answer- organize diagnosis that relate to similar physiological systems computer aided translators - Answer- using technology to translate language or coding

Evaluation and Management (E/M Codes) - Answer- 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 who determines whether a mobile application is regulated for medical use - Answer- FDA are mobile apps intended to provide access to electronic copies of medical textbooks with generic text search capabilities considered a medical devices? - Answer- No recuasse they are reference materials and not tools for dx of disease or condition are mobile apps that are intended for healthcare providers to use as educational tools for medical training a medical device? - Answer- No, they are intended for general user education and not for dx medical devices - Answer- Any equipment, instrument, implant, material, or apparatus used for the diagnosis, treatment, or monitoring of patients. what makes a medical app not a medical device - Answer- 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. Privacy - Answer- Practice of maintaining the security and confidentiality of patient records. Confidentiality - Answer- The act of holding information in confidence, not to be released to unauthorized individuals. cybersecurity - Answer- - Measures taken to protect a computer or computer system against unauthorized access or attack APN role in cybersecurity - Answer- determine if appropriate safeguards to protect phi are in place and if HIPPA requirements are met Who is the main regulatory agency of cybersecurity - Answer- FDA

examples of mobile apps that the FDA intends to enforce discretion on - Answer- 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 definition of Medical Device Data Systems Are all medical mobile applications also medical devices - Answer- no FDA oversight on medical devices contain - Answer- oversees mobile apps that are medical devices and whose functionality could pose a risk to a patient's safety if the mobile app were to not function as intended.

• Also oversee the cybersecurity management of these devices as well as the hospital network security. who regulates medical devices - Answer- FDA major areas for mHealth growth - Answer- preventative medicine and health promotion can be utilized through education and awareness apps portable dx devices that allow monitoring of human conditions in clinical or offsite locations Applications for data management, training medical personnel, and mobile payments POE/CPOE/CDS - Answer- POE- practitioner order entry, CPOE- computerized practitioner order entry, CDS- clinical decision support clinical decision support systems - Answer- a computer-based program designed to assist clinicians in making clinical decisions by filtering or integrating vast amounts of information and providing suggestions for clinical intervention Human Technology Interface - Answer- The hardware and software through which the user interacts with any technology. for example computers patient monitors and telephones. The human technology interface

addresses the user's ability and the technologies functionality to complete the task demand. Human information technologies (HIT) - Answer- hardware software integrated technologies are related licenses intellectual property upgrades or packaged solutions sold as services that are designed for or support the use by healthcare entities or patients for the electronic creation maintenance access or exchange of health information patient-centered information systems - Answer- patient centered information systems focused on collecting data and disseminating information related to direct care four most common types of PCS systems - Answer- clinical documentation systems pharmacy information systems laboratory information systems radiology information systems Evaluation and Management Coding - Answer- process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing. Three major questions must be asked when identifying an E/M code: - Answer- 1) Is the patient new or established?

2. Where is the service provided?
3. What is the degree of the service rendered? What makes someone a new patient - Answer- has not received service from a provider in the practice within 3 years What is necessary for establishing E/M Codes - Answer- Place of Service; Type of Service; Patient Status Components of Risk Based E/M Coding - Answer- History; Physical; Medical Decision Making

Medical Decision Making (MDM) in regards to E/M codes - Answer- 1 of 3 components to establishing E/M codes; way of quantifying the complexity of thinking that is required for the visit. Medical Decision Making (MDM) - Answer- 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 3 key elements to medical decision making - Answer- risk data dx Reimbursement Coding - Answer- - 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. DRG vs MDC - Answer- DRG- facilitates payment through prospective payment system MDC-organizes dx that affect similar physiological systems both primary purpose for billing medical billing - Answer- process of submitting claims to receive payment medical coding - Answer- codes to communicate procedures performed and why each billing claim must contain what two things - Answer- A CPT (procedural)code and ICD-10 (dx) code Why do you need a cpt and an ICD code - Answer- to determine reimbursement. if dx does not explain need for the procedure there is no payment

how many levels of care are there for e/m coding and what are they - Answer- 5 Minimal/RN visit Problem focused exp problem focused detailed comprehensive E/m coding for each level of a new patient - Answer- Minimal/RN visit- 99201 Problem focused- 99202 exp problem focused- 99203 detailed- 99204 comprehensive- 99205 E/m coding for each level of an established patient - Answer- Minimal/RN visit- 99211 Problem focused- 99212 exp problem focused- 99213 detailed- 99214 comprehensive- 99215