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NR599: Final Exam Study Guide
1. Nursing informatics: specialty that integrates nursing science, computer sci- ence, and
information science to manage and communicate data, information, and knowledge in nursing practice
2. Levels of Nursing Informatics Practice: Generalist and Informatics Nurse Spe- cialist
3. Informatics Nurse Specialist: Completed graduate level education in informat- ics or related
field
4. Knowledge: The awareness and understanding of a set of information and the ways that
information can be made useful to support a specific task or reach a decision.
5. Knowledge Workers: Those who work with information and generate knowledge as a product.
Nurses are an example of such.
6. Wisdom: the ability to apply valuable and viable knowledge, experience, under- standing and
insight while being prudent and sensible. Sometimes considered the highest form of "Common Sense"
7. Scientific Underpinning: Provide the basis of knowledge to advance nursing practice;
include sciences such as biology, physiology, psychology, ethics, and nursing. -DIKW Paradigm (Data, Information, Knowledge, Wisdom)
8. Foundation of Knowledge model: Model that proposes that humans are organic information
systems constantly acquiring, processing, and generating information or knowledge in both their professional and personal lives.
9. Computer Science: Study of storage, conversion and transformation, transfer or transmission
of information in computers through algorithms and practical imple- mentation problems.
10. Cognitive Science: Studies how the mind works from an information processing perspective.
11. Information Science: The study of the retrieval, application, use and manage- ment of
information as well as the human-computer interaction.
12. Standard Terminologies: Structured, controlled languages developed to repre- sent concepts
in a given domain in a clear, unambiguous fashion that conveys the exact same meaning for data, information, and knowledge across settings, regions, and even different countries.
13. Nomenclature: Refers to a system of rules and procedures for adding names used in an art
or science, such as nursing.
14. Classification: Systems that capture categories, which are then used to de- termine costs
or outcomes but are insufficient in detail for clinical documentation purposes
25. Information literacy: Ability to identify when information is needed as well as the skills to
find, evaluate, and effectively use the same
26. Computer Literacy: Basic familiarity with computer uses and common applica- tions, ability
to navigate hyperlinks, able to set up and use a database to collect and retrieve information
27. Clinical Information Management: -Uses clinical decision making (CDS) and system
safeguards to protect patients and protected health information (PHI) -Able to request and evaluate reports for the purpose of informed decision making -Participate in the selection, design, and evaluation of clinical information systems and patient- care technologies -Uses available technologies to appropriately and effectively communicate
28. Health Literacy: a person's capacity to obtain, process and understand basic health
information and services, and to use these resources to promote one's health and wellness
29. Clinical Decision Support System (CDSS): provides timely information, usu- ally at the point
of care, to help inform decisions about a patient's care.
30. Meaningful Use (MU): The set of standards defined by the Centers for Medicare & Medicaid
Services (CMS) Incentive Programs that governs the use of EHRs and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria.
31. HITECH Act: -Health Information Technology for Economic and Clinical Health Act was
enacted to promote the adoption and meaningful use of health information technology. -Monetarily Incentivize health organizations and providers to become meaningful users of EHR. -Introduced in 2009 as part of the American Recovery and Reinvestment Act (ARRA)
32. Digital Natives: a generation of people born after 1980 who have been raised in a digital
age
33. Human Technology Interface (HTI): The portion of the assistive technology system with which
the user interacts; The hardware and software through which the user interacts with any technology.
34. Patient Centered Information System: -Systems focused on augmenting tra- ditional
approaches to health information management
-Designed to support patient participation in health care decision making and treatment activities.
35. Electronic Medical Record (EMR): Patient medical record from a single med- ical practice,
hospital, or pharmacy
36. Information Literacy Competency Standards for Nurses: -Determine the extent of
information needed -Access the needed information effectively and efficiently -Critically evaluate the information and sources
infrastructure. -The use of wireless communication to support efficiency in public health and clinical practice.
49. Mobile Medical Applications (Apps): -Accessories to a regulated medical device or are a
software that transforms a mobile platform into a regulated medical device. -Facilitates mHealth
50. Medical Devices: Any equipment, instrument, implant, material, or apparatus used for the
diagnosis, treatment, or monitoring of patients.
51. Non-Medical Devices: -Applications within a device not intended for use in the diagnosis of
disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease. -Does not require FDA oversight
52. Food and Drug Administration (FDA): -Regulatory body that 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.
53. (POC) Point of Care: Testing and diagnosis at the patient's side and can be conducted
anywhere the patient is, such as the home, physician office, ambulance, or hospital bedside
54. Confidentiality: The act of holding information in confidence, not to be released to
unauthorized individuals.
55. Cybersecurity: -Measures taken to protect a computer or computer system against
unauthorized access or attack. -FDA is main regulatory agency
56. Computer-aided Translators: A person who uses computer software to convert source code to
target text; A conversion of computer language from one to another
57. HIPPA (Health Insurance Portability and Accountability Act): Enacted in 1996; federal law that
required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge.
58. ICD-10 Codes: -Alphanumeric codes used by doctors, health insurance compa- nies, and
public health agencies across the world to represent diagnoses.
-Shorthand for the patient's diagnosis , which are used to provide the payer infor- mation on the necessity of the visit or procedure performed
59. Evaluation and Management Coding: process by which physician-patient en- counters are
translated into five digit CPT codes to facilitate billing.
60. Necessity prior to establishing Evaluation and Management Codes: Place of Service; Type of
Service; Patient Status
61. Components of Risk Based E/M Coding: History; Physical; Medical Decision Making
62. Medical Decision Making (MDM): 1 of 3 components to establishing E/M codes; way of
quantifying the complexity of thinking that is required for the visit.
63. 3 key elements to medical decision making: risk, data, and diagnosis
64. Reimbursement Coding: -Codes assigned contingent upon data input from clinical team
members based on a summative review of the clinical record by trained coders. -Reimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes.
65. 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
66. Major Diagnostic Categories (MDCs): organized diagnoses that affect similar physiological
systems used in reimbursement billing and coding.
67. Clinical Support Tools: -Found in EHR software that when applied effectively, can enhance
patient care quality and outcomes, improve efficiency, and help to ensure regulatory compliance. -Process designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient specific interventions, assess- ments, recommendations, or other forms of guidance for clinicians, patients, and others involved in care delivery.
68. Alert Fatigue: Main challenge to effective implementation of CDS Tools
69. Primary Goal of CDS Tools: leverage data and the scientific evidence to help guide
appropriate decision making.
70. Workflow: -Term used to describe the action or execution of a series of tasks in a prescribed
80. Medical Coding: Assignment of codes to communicate to payers (insurance companies) in
relation to services performed by a healthcare provider and for what reason they were performed;
81. Medical Billing: Process of submitting and following up on claims made to a payer in order
to receive payment for medical services rendered by a healthcare provider
