PD1: Key Concepts of E-Documentation in Health Information Technology Systems Sherpath

In which way would health information be collected, organized, and conveyed to others?

Patient notes

Interdisciplinary rounds

Insurance audits

Documentation

Documentation

Correct answer

Documentation is the process in which information collected is organized electronically and conveyed to others for multiple purposes.

Which element would fall under the meaningful use criteria of the Centers for Medicare and Medicaid Services?

Enhanced security features

Shared health information between health facilities

Access for patients to health records

Computerized clinical decision-making

Access for patients to health records

Correct answer

Meaningful use criteria require that patients have access to their electronic health records and the option to review, revise, and add to their medical, surgical, and family history as needed.

Match the key concept of electronic records with the appropriate description.

Match each option below to proceed to the next question.

Communication between systems to share pertinent patient information.

Records following the patient with care transitions

Select an answer

Access at the point of care virtually or in person

Ease of Access

Accountability

Interoperability

Portability

Communication between systems to share pertinent patient information.

Interoperability

Records following the patient with care transitions

Portability

Access at the point of care virtually or in person

Ease of Access

Which example would be a time saving mechanism within the electronic health record (EHR)?

Select all that apply. One, some, or all responses may be correct.

Automatic downloading of vital signs to the EHR

Free text entry options for documentation of assessment

Medication dose calculators

Automated discharge summaries

Two factor authentication for security

Automatic downloading of vital signs to the EHR

Correct answer

Automatic recording of vital signs saves the nurse time by recording and tracking vitals without manual input requirements.

Medication dose calculators

Correct answer

Medication dose calculators may be able to calculate the patient’s needed dose based on existing chart inputs and save time finding information and making manual calculations.

Automated discharge summaries

Correct answer

Automated discharge summaries are available based on information already present in the EHR. This saves the nurse from collecting information and compiling a summary.

Which element would be an advantage of electronic documentation?

Select all that apply. One, some, or all responses may be correct.

Reduced visibility of nursing care

Exchange of information among providers

Continuity of care

Improved quality of nursing care

Patient safety

Inaccurate records

Exchange of information among providers

Correct answer

Electronic documentation makes access to records much quicker so that healthcare providers can update and share information in the record instantly.

Continuity of care

Correct answer

Electronic documentation supports continuity of care through easy categorization of information and transfer of information between systems.

Improved quality of nursing care

Correct answer

Documentation in EHRs can improve the quality of nursing care and improve communication.

Patient safety

Correct answer

Electronic documentation can improve patient safety by providing clarity and decision support systems to health care providers.

Which information would be used as the basis for quality of care assessments?

Nursing summaries of care

Verbal report amongst healthcare providers

Patient satisfaction surveys

Documentation in the electronic health record (EHR)

Documentation in the electronic health record (EHR)

Correct answer

Quality of care assessments are made based on what is documented and coded in the EHR.

Which type of analysis would be performed to identify trends in infectious disease outbreaks?

Epidemiological trend analysis

Quality analysis

Aggregation analysis

Financial analysis

Epidemiological trend analysis

Correct answer

Epidemiological data and trend analysis is used to review trends in healthcare, treatment patterns, and disease outbreaks from large volumes of health records.

Which benefit would be achieved by using a computerized provider entry system (CPOE)?

Increased number of orders entered

Quicker entry of data into the EHR

Reduced cost of data entry

Improved accuracy of orders

Improved accuracy of orders

Correct answer

Orders tend to be more appropriate with CPOE due to decision support tools in place and alerts within the EHR.

Which measure would be implemented to help protect the security of the electronic health record (EHR)?

Select all that apply. One, some, or all responses may be correct.

Using automatic log-offs

Mentioning social security number on patient records

Applying keyed locks on hard drives

Notifying patient of information sharing

Ensuring workstation security

Using automatic log-offs

Correct answer

Using automatic log-offs prevents the electronic health record (EHR) from being left open to access by other individuals which may breach security protocols.

Applying keyed locks on hard drives

Correct answer

Applying keyed locks to hard drives to prevent inappropriate removal and access protects EHR security.

Notifying patient of information sharing

Correct answer

Notification to the patient when health information is shared may allow the patient to monitor safety and use of their records to improve security.

Ensuring workstation security

Correct answer

Workstation security features help to prevent review and inappropriate access of the EHR by unauthorized individuals.

Which purpose would documentation serve?

Select all that apply. One, some, or all responses may be correct.

Organizing patient health information

Increasing workload

Conveying patient health information to others

Allowing aggregate review to determine “best practice”

Engaging the patient in technology

Organizing patient health information

Correct answer

Documentation serves to obtain and organize health data and patient information.

Conveying patient health information to others

Correct answer

Documentation is used to communicate health data and patient status to others on the care team.

Allowing aggregate review to determine “best practice”

Correct answer

Documentation allows for review of records across large data sets to determine best practices for medical and nursing care.

In which way would the use of the electronic health record (EHR) improve care outcomes?

Assist in determination and implementation of best practice.

Reduce the need for communication amongst care providers.

Increase time spent with patient.

Provide standardized terminology for care.

Assist in determination and implementation of best practice.

Correct answer

Aggregate data review allows for identification of best practice that can be implemented into patient care.

Which benefit would arise from patients having access to their medical record through the electronic health record (EHR)?

More rapid information sharing

Increased patient engagement in care

Improved understanding of health conditions

Reduction in cost of care

Increased patient engagement in care

Correct answer

Studies have demonstrated that allowing patients access to records increases their engagement in care and self-management of disease.

Which example would demonstrate the way in which the electronic health record (EHRs) can improve safety?

Information entered into the record rapidly by the RN

A standardized set of abbreviations used for documentation

Documentation in one section of the record transferred to another summary section

An alert prompt to the nurse to enter patient weight into the system

A standardized set of abbreviations used for documentation

Correct answer

EHRs often required standardized nursing terminology and a standardized set of abbreviations to be used, this eliminates uncertainty due to inappropriate or illegible abbreviations that may cause medical error.

Which disadvantage would result from electronic documentation?

Select all that apply. One, some, or all responses may be correct.

Information is exchanged among multiple healthcare team members.

Individualized care is not accurately reflected.

Records may be left incomplete.

Decision support and automated alerts change data entry.

Nursing care may be difficult to classify for entry.

Individualized care is not accurately reflected.

Correct answer

Individualized patient care and certain aspects of nursing care are not easily documented in the EHR which may be a disadvantage.

Records may be left incomplete.

Correct answer

Records at times are left incomplete due to difficulty capturing certain care.

Nursing care may be difficult to classify for entry.

Correct answer

Nursing care information may be difficult to classify and thus does not always get entered into the record.

Which source would be used to demonstrate effective care provision during accreditation reviews?

Nursing interviews

Patient satisfaction surveys

Clear documentation

Manager evaluations

Clear documentation

Correct answer

Clear documentation provides information about the care provided to patients and is used in accreditation reviews.

Which type of analysis would reveal a pattern of success with a specific surgical treatment option?

Aggregate data analysis

Epidemiologic data trend analysis

Outcome analysis

Financial analysis

Outcome analysis

Correct answer

Outcome analysis looks at the results of patient care or medical treatment such as the outcomes of a surgical procedure.

Which alert would result from the use of a clinic decision support system (CDSS) in the electronic health record (EHR)?

A prompt to enter a password to enter the EHR

A prompt to order liver enzyme testing for patients on cholesterol medication

A prompt to log off the EHR after a period of inactivity

A prompt to enter patient vitals prior to medication administration

A prompt to order liver enzyme testing for patients on cholesterol medication

Correct answer

A prompt to order testing based on a condition or treatment is a function of the CDSS to improve monitoring and safety.

Which consequence would arise from inappropriate access of a patient health record?

Select all that apply. One, some, or all responses may be correct.

Discrimination at the workplace

Disqualification for health services

Loss of medications

Identity theft

Delay in receiving medical treatment

Discrimination at the workplace

Correct answer

Information being released to unauthorized individuals could lead to discrimination against the patient in a variety of settings including the workplace.

Disqualification for health services

Correct answer

In some settings, information being inappropriately shared might reduce access to care or disqualify the patient from certain health services.

Identity theft

Correct answer

Identify theft might occur from unauthorized access to records which contain sensitive and security patient information.