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NSG 310 TOPIC 12 FINAL EXAMS.
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NSG 310 TOPIC 12 FINAL EXAMS.
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NSG 310 TOPIC 12 FINAL EXAMSTopic 12: Health Care Information Systems and Management I
1. Describe documentation systems in various settings.
• EHR –has been used as a generic term for all electronic health care records in document
systems that are portable (can follow client to other providers, specialists, other
hospitals, nursing homes, etc.
• EMR – legal record created in hospitals and ambulatory environments that is the source
of data for the HER at that facility
• HIT – Health information technology provides improved communication flow that is fast,
timely, and available to all stakeholders (docs, nurses, client/family, pharmacy, etc.)
• CPOE – Computerized provider order entry = systems put into place for safety
• CDSS – clinical decision support provided via data collected on client to help team with
clinical decisions
• Centers for Medicare and Medicaid Services (CMS) have set up Health Information
Technology standards in US
• PHR – Patient healthcare record: information that can be managed by the client
o Clients can create their own records from collection of visit information from a
variety of providers
o Clients can access their own records from healthcare provider web based
encrypted sites to view and print
o The systems set up from providers contain personal healthcare records that are
private just for consumers and not shared; however, client can take that
information and share it with another provider
o In some cases, clients can add to their providers information for the EHR kept by
that provider (i.e. scan in labs or other healthcare information from another
provider for primary provider records)
2. Identify standard components of the electronic medical record (EMR).
• Attributes identified by the Institute of Medicine (IOM) provide the basis for today’s
understanding of the EHR
o Secure, reliable access where and when needed
o Records and manages episodic & longitudinal information
o Primary information source during care
o Assists with planning and delivery of evidence-based care
• Captures data for:
o Quality improvement, utilization review, risk management, resource planning,
performance management
• EHR components
o Information needed for medical record and reimbursement purposes
o Longitudinal, masked information supports clinical research, public health
reporting, and population health initiatives
o Supports clinical trials and evidence-based research
o Client safety & security of private health information
, o Restructures healthcare delivery system to improve the quality of care
o Cost containment
3. Explain the role of the EMR as a legal document, including nursing responsibilities.
• Healthcare records are legal documents
• Criminal investigations
• Financial impact
• Keep it confidential – Privacy laws
o Residence information
o Ethnicity/Sex/Birthdate
o Possibly whole or part of SSN
o Diagnosis
• Cyber-crimes are on the rise
• Data contains personal client information
• Protect from unauthorized users
• Maintain secure password management
• Automatized sign on (scanners)
• Grant access only on need to know basis
• Maintain professionalism
• Misuse & Consequences
o Negative comments may constitute hostile environment
o Civil and criminal penalties
o Fines/jail time
o Personal liability
o Termination of employment
o Poor publicity for hospital
o Board of Nursing will investigate mismanagement of client records, unethical
conduct, and breaches in confidentiality
4. Determine how nurses integrate data management into daily nursing practice.
• Nursing role in healthcare with HIT
o Lead and assist in IT development
o Timely, accessible documentation
o Reduce medication errors
o Collaborate with physicians/other team members
o Assist in policy development
o Data mining/research for best practices
• EHR documentation
o Why do I document?
o Show client response to care
o Compile date from many clients to identify “best practice”
o Give evidence for reimbursement
o Provide proof of quality care
o Make a permanent record of care given
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