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NSG-310 Final Exam with Latest Update
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NSG-310 Final Exam with Latest Update
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NSG-310 Final Exam with Latest UpdateElectronic Health Record (EHR) - Answer-generic term for ALL electronic health care
records in document systems (can follow client to other providers, hospitals, etc.)
Electronic Medical Record (EMR) - Answer-Patient medical record from a SINGLE
medical practice, hospital, or pharmacy
Health Information Technology (HIT) - Answer-technology that is used to record, store,
and manage patient health care information
improves communication
Computerized provider order entry (CPOE) - Answer-safe system where health care
providers can directly enter orders for patients
Clinical decision support systems (CDSS) - Answer-provided via data collected on client
to help team with clinical decisions
Centers for Medicare/Medicaid Services (CMS) - Answer-federal agency that has set up
Health Information Technology (HIT) standards in the US
"meaningful use" - Answer-HIT standards for providers that create continuity for quality
and safety
Health Information Exchange (HIE) - Answer-an electronic system that allows providers
and patients to view online/download their records
Parts of the EMR - Answer-Nursing, medical imaging, radiology, pharmacy, labs,
physicians, social work, ordering
Misuse & consequences - Answer-Board of Nursing will investigate mismanagement of
client records, unethical conduct, & breaches in confidentiality
Nursing role in healthcare with HIT - Answer--Lead/assist in IT development
-Timely documentation
-Reduce med errors
-Collaborate with physicians
Why do nurses document? - Answer-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... - Answer-Pharmacy refills machines
routinely & any meds not in system can be requested from pharmacy
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