Deck 15: The Role of Standardized Terminology and Languages in Informatics

Question 1

A classification system is used to categorize the details of the clinical encounter. Which of the following does a classification system not do?

A)Group data to determine costs and outcomes of treatment
B)Captures the level of detail necessary to document specific items at the point of care
C)Provides data to consumers on costs and outcomes of treatment options
D)Used in the collection and reporting of health statistics

Answer 1

Captures the level of detail necessary to document specific items at the point of care

Question 2

The impact of standardized terminology throughout the U.S. health care system has grown exponentially. Medicare and Medicaid have begun to offer financial incentives to health care providers to promote adoption and meaningful use of interoperable health information systems and a qualified health record. Which of the following statements best describes meaningful use?

A)The goal of meaningful use is to input data in a manner that creates evidence-based practice models.
B)The goal of meaningful use is to exchange clinical structured data in a manner that is accurate and complete to improve patient care in a cost-efficient way.
C)The goal of meaningful use is to provide a warehouse of data that supports medication renewal and patient teaching plans.
D)The goal of meaningful use is to offer the clinician patient care tools for improved outcomes.

Answer 2

The goal of meaningful use is to exchange clinical structured data in a manner that is accurate and complete to improve patient care in a cost-efficient way.

Question 3

Which of the following is a nursing classification designed to document the six steps of the nursing process across the care continuum?

A)International Classification of Nursing Practice (ICNP)
B)NANDA International Nursing Diagnoses
C)NANDA-I Taxonomy II
D)Clinical Care Classification (CCC) System

Answer 3

Clinical Care Classification (CCC) System

Question 4

Gonzalez is scheduled to undergo a hip replacement after he slipped on an icy step. During the preoperative phase, the nurse begins to enter the assessment findings into the database. Which of the following standardized terminologies will the nurse most likely use?

A)The Omaha System
B)The PeriOperative Nursing Data Set (PNDS)
C)North American Nursing Diagnosis International (NANDA-I)
D)International Classification of Nursing Practice (ICNP)

Question 5

The American Nurses Association established criteria for recognizing standardized terminologies. The terminologies must meet established criteria to be approved. Which of the following are instrumental in the approval process?

A)Outcome identification
B)Diagnosis
C)Problem solving
D)Decision making
E)Nursing process data elements

Question 6

The use of which of the following is a means of ensuring the data collection is accurate and valid?

A)Standardized terminology
B)Tablets
C)Bar coding
D)Handheld devices

Question 7

Standard terminologies have been scientifically investigated for their effectiveness and impact on patient care. The use of standard terminologies can, therefore, facilitate the use of which of the following?

A)Multiple support languages
B)Consumer informatics
C)Computer literacy
D)Evidence-based practice and decision support rules

Question 8

______________________________ is a globally recognized controlled health care vocabulary that provides a common language for electronic health applications.

Question 9

Which of the following answers depicts the use of the ANA recognized nursing classifications to codify data?

A)The ANA recognized nursing classifications codify data used during the nursing process such as assessments, nurse sensitive problems, interventions, and outcomes.
B)The ANA recognized nursing classifications codify data is used to support input devices.
C)The ANA recognized nursing classifications align nursing outcomes.
D)The ANA recognized nursing classifications codify data for retrieval of billing invoices.

Question 10

Which of the following terminologies have been approved by the American Nurses Association?

A)Nursing Management Minimum Data Set (NMMDS)
B)Nursing Minimum Data Set (NMDS)
C)Alternative Billing Codes (ABC Codes)
D)Clinical Care Classification (CCC)
E)North American Nursing Diagnosis International (NANDA-I)

Question 11

During the orientation to the renal oncology unit, the head nurse demonstrated the usefulness of the Clinical Care Classification (CCC) System. Throughout the demonstration, the head nurse discussed the value of the system to patient care. Which of the following statements best reflects the usefulness of CCC?

A)The Clinical Care Classification (CCC) System facilitates the collection and dissemination of lab values.
B)The Clinical Care Classification (CCC) System offers improved outcomes.
C)The Clinical Care Classification (CCC) System facilitates patient care documentation at the bedside.
D)The Clinical Care Classification (CCC) System discloses standardized nursing terminologies.

Question 12

Terminologies can be incorporated within the electronic health record (EHR) thereby improving practice. Which of the following are considered uses for this technology in health care?

A)Classification
B)Reference
C)Point of care
D)Coding
E)Denial of claims

Question 13

The ANA has recognized the Omaha System and integrated the terminology into SNOMED CT. Which of the following best represents the value of the Omaha System?

A)The Omaha System is a problem classification scheme.
B)The Omaha System offers outcome labels.
C)The Omaha System provides nursing diagnoses.
D)The Omaha System provides diagnoses and intervention.

Question 14

The Omaha System has a multitude of functions. The system can store data describing problems, symptoms, modifiers, interventions, and outcomes. One of the benefits of the stored data is which of the following?

A)Decreasing services to elderly
B)Allowing patient input of data
C)Researching quality and effectiveness
D)Decreasing time spent with data collection

Question 15

The use of standardized nursing terminology will result in better ______________________ among the interdisciplinary team.

Question 16

The use of SNOMED CT within electronic health records has multiple benefits. Which of the following are considered benefits of SNOMED CT?

A)Provides interoperable data collection that can be analyzed and used for evidence-based practice models
B)Provides interoperable data collection that can be analyzed and used for decision support rules
C)Provides interoperable data collection that can be analyzed and used in reporting quality measures
D)Provides interoperable data collection that can be analyzed and used for medication renewals
E)Provides interoperable data collection that can be analyzed and used for administrative billing

Question 17

_______________________________________ is standardized classification of interventions that describes the activities that nurses perform.

Question 18

Which of the following can be used to document the elements of the nursing process within the care plan?

A)The Omaha System
B)The PeriOperative Nursing Data Set
C)Personal health record
D)NANDA-I

Question 19

Which of the following terms is defined as structured and controlled languages that have been developed according to terminology development guidelines?

A)Standardized terminologies
B)Health care standards
C)Health care terminology
D)Health information standards

Question 20

Clinical terminologies consist of concepts that support which of the following facets of health care?

A)Diagnostic studies
B)History and physical examinations
C)Visit notes
D)Ancillary department information
E)Outcomes measures

Question 21

___________________________ facilitates the monitoring of trends and problems of the health of populations, developing clinical decision support, and expanding our knowledge of diseases and treatments and outcomes through research and clinical data mining.

Question 22

Meaningful use requirements mandate the use of _________________________ for data collection and reporting of established quality measures.

Question 23

In the last decade, and with the requirement to build EHRs that meet the 2009 meaningful use criteria, the use of which type of data has expanded to include pay-for-performance initiatives, care coordination, patient safety monitoring, and public health surveillance?

A)Patient
B)Coded
C)Embedded
D)Qualitative

Question 24

Multiple benefits have emerged from the use of structured terminologies within health care records. Which of the following are considered benefits of the health information technology (HIT)?

A)Accurate, consistent meaning of data is collected and shared across the health care system.
B)A plethora of data can be entered into the system manually.
C)Clinical terminology enables the capture of data at the level of detail necessary for patient care documentation.
D)Standardization in nursing documentation supports research across settings on patient outcomes and interoperability.
E)Patient identification and outcomes are clearly shared throughout the systems.

Question 25

Implementing standardized terminology has many benefits to multiple beneficiaries. Which of the following are benefits of standardized terminology?

A)Patients
B)Providers
C)Health care organizations
D)Health care industry
E)Informational technicians