Exam 15: The Electronic Health Record and Clinical Informatics

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As a healthcare professional in the field of nursing, I believe that an electronic health record (EHR) should support documentation and knowledge management functions in a way that enhances patient care and streamlines workflow. If I had the opportunity to create a wish list for an EHR to support my work, I would include the following features: 1. Customizable templates: The ability to create and customize templates for nursing assessments, care plans, and progress notes would greatly improve efficiency and accuracy in documentation. 2. Integration with clinical decision support tools: Access to evidence-based guidelines, protocols, and best practices within the EHR would support knowledge management and help guide clinical decision-making. 3. Interdisciplinary communication tools: Seamless communication and collaboration with other healthcare team members, such as physicians, pharmacists, and therapists, would improve care coordination and information sharing. 4. Robust search functionality: The ability to easily search and retrieve relevant patient information, clinical guidelines, and educational resources would support knowledge management and facilitate evidence-based practice. 5. Education and training resources: Access to educational materials, training modules, and professional development resources within the EHR would support ongoing learning and knowledge management for nursing staff. 6. Data analytics and reporting capabilities: The ability to generate reports and analyze data related to nursing interventions, patient outcomes, and quality metrics would support evidence-based practice and quality improvement initiatives. Overall, an EHR designed to support nursing documentation and knowledge management should prioritize user-friendly interfaces, interoperability with other systems, and robust clinical decision support tools to enhance patient care and streamline workflow for nursing professionals.

A) Possible barriers to implementation of the electronic health record
B) Key metrics to measure success of the electronic health record
C) When to host end-user usability testing sessions
D) Staff training needs for the electronic health record

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A) Decision support system
B) Cost savings function
C) Physician assist system
D) Testing management system

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A) "The National Institute of Standards and Technology performs this certification."
B) "Certification is performed by the healthcare organizations locally."
C) "The Centers for Medicare and Medicaid Services conducts this certification."
D) "The medical associations of each state conduct these certifications."

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A) disciplinary measures for addressing resistance by professionals.
B) involving subject-matter experts to validate workflow.
C) hosting end-user usability testing sessions.
D) formal training activities.

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A) medication lists.
B) allergies.
C) test results.
D) All of these are correct.

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Interoperability and a shared EHR (Electronic Health Record) raise several ethical considerations that need to be addressed. Firstly, there is the issue of patient privacy and data security. When multiple healthcare providers have access to a shared EHR, there is a risk of unauthorized access to sensitive patient information. It is important to ensure that robust security measures are in place to protect patient data and that only authorized personnel have access to the EHR. Secondly, there is the concern of patient consent and control over their own health information. Patients should have the right to control who has access to their EHR and how their information is shared. It is important to establish clear guidelines for obtaining patient consent and to ensure that patients are fully informed about how their data will be used and shared. Another ethical consideration is the potential for bias and discrimination in the use of shared EHR data. Healthcare providers must be aware of the potential for bias in the interpretation of EHR data and take steps to mitigate this risk. Additionally, there is a need to ensure that shared EHR systems do not perpetuate existing health disparities or lead to discrimination against certain patient populations. Finally, there is the issue of accountability and responsibility. When multiple healthcare providers are involved in the use of a shared EHR, it can be challenging to determine who is ultimately responsible for the accuracy and integrity of the data. Clear guidelines and protocols need to be established to ensure accountability and to address any errors or discrepancies in the EHR. In conclusion, the ethical considerations related to interoperability and a shared EHR are complex and multifaceted. It is essential to prioritize patient privacy, consent, and control over their health information, as well as to address issues of bias, discrimination, and accountability in the use of shared EHR systems. By addressing these ethical considerations, we can ensure that interoperability and shared EHRs benefit patients and healthcare providers while upholding ethical standards.

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If I was asked about a diagnosis with wh...

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A) "There is faster turnaround time for laboratory results in the EHR."
B) "Doctors' orders are harder to interpret in the EHR."
C) "Medication recalls are not effectively communicated to patients in the EHR."
D) "The EHR helps reduce the amount of nursing documentation for every patient."

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True

A) Data warehousing
B) Results management
C) Digital manipulation
D) Electronic searching

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A) the president discussed electronic health records in the State of the Union address.
B) monetary incentives and potential penalties were administered by the Centers for Medicare and Medicaid Services.
C) implementation support was provided by information technology professionals.
D) All of these are correct.

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