∙ 1.What is an ELECTRONIC MEDICAL RECORD (EMR). Describe an EMR.
1. A nursing informatics specialist is conducting a presentation about the electronic
medical record (EMR) to a group of facility staff. Which statement would the nurse
specialist most likely include when describing the EMR?
A) The EMR is transportable.
B) The data in the EMR are owned by the client.
C) It describes the care rendered during an agency visit.
D) The EMR lacks standardized vocabulary.
∙2. Most important benefit of electronic documentation system
2. An electronic documentation system will be implemented in an agency. As part of the
process, the staff is receiving education about the system and the overall benefits. Which
benefit would be mentioned as the most important?
A) Availability of an audit trail for information
B) Decreased decentralization of the healthcare delivery system
C) Enhanced ability to extract information
D) Improvement in client care outcomes
3. A group of nurses are reviewing information related to the Health Information
Technology for Economic and Clinical Health (HITECH) Act. The group demonstrates
understanding of this act when they identify which examples as core objectives for
supporting healthcare during stage 1? Select all that apply.
A) Performing medication reconciliation
B) Including clinical lab test results in the EHR
C) Using computerized provider order entry
D) Using a clinical decision support rule
E) Sending secure client reminders for follow-up care
∙ 3. Strengths and weaknesses of paper and electronic documentation
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4. A nurse is preparing a presentation to a group of staff members comparing paper and
electronic documentation. Which weaknesses of paper records would the nurse include?
Select all that apply.
A) Legibility
B) Lack of a backup system
C) Difficult to transport
D) Slowness in charting
E) Easily damaged
5. A nurse is reviewing a client's electronic health record. Based on the nurse's
understanding of data standards, which would the nurse identify as defining what data
are shared?
A) Clinical Document Architecture
B) Continuity of Care Document
C) Health information system
D) Electronic medical record
6. A nurse is reading a journal article about electronic health records and how they can fill
in the gaps between evidence and practice. Which benefits would the nurse most likely
read about? Select all that apply.
A) Monitoring quality improvement outcomes
B) Encouraging client partnering with the healthcare provider
C) Providing information about controlled clinical trials
D) Identifying information that can affect clinical outcomes
E) Allowing implementation after extensive long-term knowledge discovery
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7. A group of nurses are involved in a lively debate about the strengths and weakness of
paper documentation. Which statements would the group use to defend the position for
using paper documentation? Select all that apply.
A) "Paper records are easily transported."
B) "Paper records are much more complete."
C) "Paper records are quick to retrieve."
D) "Paper records are permanent."
E) "Paper records from past stays are easy to obtain."
8. A nursing informatics specialist has been asked to prepare a presentation for a group of
staff nurses about an electronic documentation system that is being implemented in the
facility. Which features would the nurse specialist include as promoting continuity of
care? Select all that apply.
A) Ability to have real-time documentation
B) Inclusion of an audit trail about detailed record access
C) Use of decision support systems and alerts
D) Ability to obtain trends about practice
E) Ability for instant communication among providers
9. When describing meaningful use, which statement would be most appropriate to
include?
A) Use of information from EHRs to improve healthcare delivery
B) A way to provide a picture of a client's health information
C) A means for providing a common structure for clinical documents
D) Use of an audit trail to identify information about record access
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10. Which component is associated with HIPAA law? Select all that apply.
A) Outcomes
B) Privacy
C) Client engagement
D) Security
E) Care coordination
11. A new graduate nurse is working at a facility that uses electronic documentation. The
nurse has questions about the policies and procedures related to data security. The nurse
would identify which person as being responsible for the policies and procedures related
to data security?
A) Nurse manager
B) Nursing informatics specialist
C) Client's primary care provider
D) HIPAA security officer
12. A nurse is working on a committee that is involved with electronic documentation. The
committee is currently working on stage 1. On which action would the committee be
focusing?
A) Advanced clinical processes
B) Data analysis for improved care
C) Data capturing and sharing
D) Improve outcomes
13. While working as a member of a group tasked with addressing meaningful use with
electronic data, the group has met the criteria for stage 1 and is now moving onto stage
2. Which action would now become a focus for the group?
A) Recording smoking status for those 13 years of age and older
B) Submitting electronic data to immunization registries
C) Transmitting prescriptions electronically
D) Maintaining an up-to-date diagnosis list
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