NSG-310 Questions with answers
well graded 100%
Electronic Health Record (EHR) - ANS✅✅generic term for ALL electronic health care records in
document systems (can follow client to other providers, hospitals, etc.)
Electronic Medical Record (EMR) - ANS✅✅Patient medical record from a SINGLE medical practice,
hospital, or pharmacy
Health Information Technology (HIT) - ANS✅✅technology that is used to record, store, and
manage patient health care information
improves communication
Computerized provider order entry (CPOE) - ANS✅✅safe system where health care providers can
directly enter orders for patients
Clinical decision support systems (CDSS) - ANS✅✅provided via data collected on client to help
team with clinical decisions
Centers for Medicare/Medicaid Services (CMS) - ANS✅✅federal agency that has set up Health
Information Technology (HIT) standards in the US
"meaningful use" - ANS✅✅HIT standards for providers that create continuity for quality and safety
Health Information Exchange (HIE) - ANS✅✅an electronic system that allows providers and
patients to view online/download their records
Parts of the EMR - ANS✅✅Nursing, medical imaging, radiology, pharmacy, labs, physicians, social
work, ordering
Misuse & consequences - ANS✅✅Board of Nursing will investigate mismanagement of client
records, unethical conduct, & breaches in confidentiality
, Nursing role in healthcare with HIT - ANS✅✅-Lead/assist in IT development
-Timely documentation
-Reduce med errors
-Collaborate with physicians
Why do nurses document? - ANS✅✅To show client response to care, give evidence for
reimbursement, provide proof of quality care, & make permanent record of care given
How automated med dispensing systems work... - ANS✅✅Pharmacy refills machines routinely &
any meds not in system can be requested from pharmacy
Nurses log onto system and choose client for med doses (some require 2 nurse IDs before
dispensing)
Technology that improves med safety... - ANS✅✅-Computerized Physician Order Entry (CPOE)
-Barcode Med Admin (BCMA)
-Electronic Med Admin Record (eMAR)
BCMA (Bar Code Medication Administration) - ANS✅✅Med is scanned by hand-held device, nurses
scan the client ID on arm band, and computer verifies that the right med was given to the right client
Do patients own their health record? - ANS✅✅NO!!! Patients have the right to access their record,
amend the record, obtain copies, and direct the record to providers, but they do not own it. They
cannot take it from provider or have it destroyed.
Information literacy - ANS✅✅skills needed to find, retrieve, analyze, and use information
(Association of College & Research Libraries-ACRL)
ACRL and IOM - ANS✅✅ACRL has developed information literacy competency standards, and the
IOM has endorsed competencies that include the ability to search for & evaluate sources of evidence
Data Management - ANS✅✅compiling information for data entry into a database for evaluation
Ex. data entry, review, charting, updating, etc.
well graded 100%
Electronic Health Record (EHR) - ANS✅✅generic term for ALL electronic health care records in
document systems (can follow client to other providers, hospitals, etc.)
Electronic Medical Record (EMR) - ANS✅✅Patient medical record from a SINGLE medical practice,
hospital, or pharmacy
Health Information Technology (HIT) - ANS✅✅technology that is used to record, store, and
manage patient health care information
improves communication
Computerized provider order entry (CPOE) - ANS✅✅safe system where health care providers can
directly enter orders for patients
Clinical decision support systems (CDSS) - ANS✅✅provided via data collected on client to help
team with clinical decisions
Centers for Medicare/Medicaid Services (CMS) - ANS✅✅federal agency that has set up Health
Information Technology (HIT) standards in the US
"meaningful use" - ANS✅✅HIT standards for providers that create continuity for quality and safety
Health Information Exchange (HIE) - ANS✅✅an electronic system that allows providers and
patients to view online/download their records
Parts of the EMR - ANS✅✅Nursing, medical imaging, radiology, pharmacy, labs, physicians, social
work, ordering
Misuse & consequences - ANS✅✅Board of Nursing will investigate mismanagement of client
records, unethical conduct, & breaches in confidentiality
, Nursing role in healthcare with HIT - ANS✅✅-Lead/assist in IT development
-Timely documentation
-Reduce med errors
-Collaborate with physicians
Why do nurses document? - ANS✅✅To show client response to care, give evidence for
reimbursement, provide proof of quality care, & make permanent record of care given
How automated med dispensing systems work... - ANS✅✅Pharmacy refills machines routinely &
any meds not in system can be requested from pharmacy
Nurses log onto system and choose client for med doses (some require 2 nurse IDs before
dispensing)
Technology that improves med safety... - ANS✅✅-Computerized Physician Order Entry (CPOE)
-Barcode Med Admin (BCMA)
-Electronic Med Admin Record (eMAR)
BCMA (Bar Code Medication Administration) - ANS✅✅Med is scanned by hand-held device, nurses
scan the client ID on arm band, and computer verifies that the right med was given to the right client
Do patients own their health record? - ANS✅✅NO!!! Patients have the right to access their record,
amend the record, obtain copies, and direct the record to providers, but they do not own it. They
cannot take it from provider or have it destroyed.
Information literacy - ANS✅✅skills needed to find, retrieve, analyze, and use information
(Association of College & Research Libraries-ACRL)
ACRL and IOM - ANS✅✅ACRL has developed information literacy competency standards, and the
IOM has endorsed competencies that include the ability to search for & evaluate sources of evidence
Data Management - ANS✅✅compiling information for data entry into a database for evaluation
Ex. data entry, review, charting, updating, etc.
