Question 1

A hospital client sees the nurse documenting information into the computer. She asks the nurse why the computer is better than the "old patient chart like hospitals have always used." Which of the following points would be accurate to say about an electronic medical record?

Accepted Answer

Electronic medical records (EMRs) offer several advantages over traditional paper records. They capture information needed for billing purposes efficiently, enhance security through controlled access and encryption, allow simultaneous access by multiple healthcare professionals, ensure availability of records whenever and wherever needed, and provide real-time data updates as patient care events occur.

Question 2

The U.S. Department of Health and Human Services indicated that the ________________ is a digital collection of patient's medical history.

Accepted Answer

EHR (Electronic Health Record) 
Rationale : The U.S. Department of Health and Human Services indicated that the Electronic Health Record is a digital collection of patient's medical history. Items included are: 
1. diagnosed medical conditions 
2. prescribed medications 
3. vital signs 
4. immunizations 
5. lab results 
6. personal characteristics such as age and weight

Question 3

Consumers are the primary source of information about their health history and medications. The patient-carried record (PCR) addresses this. Which of the following are potential problems associated with the PCR?

Accepted Answer

The patient-carried record (PCR) can face several potential problems: Loss of the record (A) can occur, making it unavailable when needed. Legibility (B) issues can arise if the record is handwritten or poorly printed, making it difficult for healthcare providers to read. Privacy (D) concerns are significant because carrying health information can lead to unauthorized access if the record is lost or seen by others. Liability (E) issues may arise if incorrect or outdated information in the PCR leads to inappropriate medical decisions. Portability (C) is actually an advantage of the PCR, not a problem, as it is designed to be easily carried by the patient.

Question 4

The Bush administration called for the adoption of the electronic health record (EHR) by 2014 as a means to help transform U.S. health care. Who owns the individual client record when an EHR is used?

Accepted Answer

The answer of The Bush administration called for the adoption...

Question 5

Which of the following is a major component of the computer-based patient record (CPR)?

Accepted Answer

The answer of Which of the following is a major...

Question 6

Which of the following statements is true about the benefits of the electronic health record (EHR)?

Accepted Answer

The answer of Which of the following statements is true...

Question 7

Which of the following topics must be addressed when giving a presentation to physicians on the benefits of the electronic medical record (EMR)?

Accepted Answer

When giving a presentation to physicians on the benefits of the electronic medical record (EMR), it is important to address topics such as easier access to previous documented encounters, facilitation of clinical pathways, chart access speed, and reduced liabilities through accurate documentation. However, trends and graphics may not be as relevant to this specific audience.

Question 8

The electronic health record (EHR) has the potential to integrate all pertinent patient information into one record. It also has potential to improve the quality of health information, patient safety, and productivity, contain costs, support research, decrease wait time for treatment and contribute to the body of health care knowledge. Which of the following are reasons why traditional paper records on clients no longer meet the needs of today's health care industry?

Accepted Answer

A) Paper records are episode-oriented with a separate record for each client visit, which makes it difficult to have a complete picture of a patient's health history.
B) Key information may be lost from one episode to the next, jeopardizing patient safety.
C) Only one person can access a paper record at any given time, which can lead to delays in patient care and coordination.
D) Different versions of the same information may be stored in several places, leading to inconsistencies and errors.
E) Paper records cannot incorporate diagnostic studies that include images and sound, which are critical components of modern healthcare.

Question 9

The EHR offers benefits to nurses, physicians, and other health care providers, the health care enterprise, and most importantly, the consumer. Much must be done before the benefits associated with the EHR can be realized. Which of the following is one action that has been proposed by experts?

Accepted Answer

Government intervention promoting information exchange among software vendors and health care systems is one action that has been proposed by experts to overcome the barriers to the realization of the benefits associated with the EHR. This will ensure seamless data exchange across different EHR systems and improve patient care coordination.

Question 10

For many years the EMR applied to a single encounter with no ability, or very limited ability, to carry information from one visit to another within a care delivery system. That situation has changed; it is now possible to bring information forward from prior visits within the organization or delivery system. Which of the following answers are basic components of the EMR system?

Accepted Answer

Clinical messaging and e-mail, results reporting, decision support, clinical documentation, and order entry are all basic components of an EMR system, facilitating communication, data management, and clinical decision-making.

Question 11

Healthcare Information and Management Systems Society (HIMSS) has defined and described the term electronic Personal Health Record (ePHR). Which of the following are included in the HIMSS definition and description?

Accepted Answer

The HIMSS definition of an electronic Personal Health Record (ePHR) includes it being universally accessible, owned and managed by the individual (or legal proxy), containing a common data set of electronic health information, and serving as a lifelong tool for managing relevant health information. It does not typically describe an ePHR as a legal record, which differentiates it from electronic health records (EHRs) that are legal records maintained by healthcare providers.

Question 12

Electronic medical record (EMR) result reporting and data repository components include unstructured data. Which of the following are examples of unstructured data?

Accepted Answer

The answer of Electronic medical record (EMR) result reporting and...

Question 13

Unlike other health records the _____________________is patient-centered, presenting a more-balanced view of an individual's health history.

Accepted Answer

The answer of Unlike other health records the _____________________is patient-centered,...

Question 14

Information in the electronic health record (EHR) may be owned by the patient or stakeholder. Which of the following about the EHR is different than the electronic medical record (EMR)?

Accepted Answer

Unlike EMRs, EHRs may allow patients or stakeholders to append information to their record if desired. The other options are incorrect. A is incorrect as EHRs may provide interactive client access. C is incorrect as EHRs may include dental records components depending on the system used. D is incorrect as EHRs may record and manage both episodic and longitudinal information.

Question 15

While most hospitals have some level of automation, few have attained a fully electronic environment. Health care Information and Management Systems Society (HIMSS) analytics created an EMR adoption model that identifies eight levels of EMR capabilities. Your hospital has been designated as a Stage 3 facility. Which of the following is accurate about an organization at Stage 3 level?

Accepted Answer

The answer of While most hospitals have some level of...

Question 16

Which of the following are major impediments to the development of an electronic health record (EHR)?

Accepted Answer

The major impediments to the development of an electronic health record (EHR) include the development of an electronic infrastructure, confidentiality concerns, the cost of development and implementation, and the lack of a common vocabulary to ensure interoperability and effective communication among different systems and providers. Information system vendors, while they can pose challenges in terms of compatibility and standardization, are not considered a major impediment in the context of this question.

Question 17

Personal health record (PHR) security issues relate to HIPAA and physical security of data. HIPAA only covers PHRs provided by covered entities such as health plans, health care clearinghouses, and providers. No governmental coverage exists for other sites unless it is at the state level. To avoid these types of breaches, the American Health Information Community's consumer empowerment working group made a recommendation. Which of the following was recommended for PHRs in order to avoid breaches?

Accepted Answer

The recommended strategy to avoid breaches in PHRs is to have a certification process. This means that the PHR providers would have to adhere to specific security and privacy standards to achieve certification. This would ensure that the authorized users of PHRs are trusted and would limit the potential for breach of sensitive data. While educating consumers and limiting authorized users could also be beneficial, a certification process would provide a more comprehensive solution to security issues. Deletion of sensitive data may be necessary in certain situations but is not a practical solution to avoid breaches overall.

Question 18

The computer-based patient record (CPR) is a comprehensive lifetime record that includes all information from all specialties. The Institute of Medicine (IOM) identified major components of the CPR that are considered to be the "gold standard" attributes. Which of the following are CPR components?

Accepted Answer

The Institute of Medicine (IOM) identified major components of the CPR that are considered to be the "gold standard" attributes. One of these attributes is providing a patient problem list, making option E the correct choice. Option A is incorrect since confidentiality is a critical aspect of the CPR. Option B is incorrect because direct entry for physicians is a feature of an electronic health record (EHR) rather than a CPR. Option C is incorrect since tools are available to measure costs in a CPR. Option D is incorrect because the CPR should provide 24/7 access to healthcare providers.

Question 19

An emerging technology related to electronic health record (EHR) progress is the use of the personal health record (PHR). PHRs store client information that will eventually contribute to the development of a comprehensive, longitudinal record. Which of the following are found in a PHR but not found in the EHR?

Accepted Answer

The answer of An emerging technology related to electronic health...

Question 20

Which of the following are found with the electronic health record (EHR) but are not found with the computer-based patient record (CPR)?

Accepted Answer

The electronic health record (EHR) includes evidence-based decision support, assists with the work of planning and delivering evidence-based care, quality management, and public health disease surveillance and reporting, which are not found with the computer-based patient record (CPR). The CPR may not necessarily have a comprehensive lifetime record that includes all information from all specialties.

Quiz 14: The Electronic Health Record

A hospital client sees the nurse documenting information into the computer. She asks the nurse why the computer is better than the "old patient chart like hospitals have always used." Which of the following points would be accurate to say about an electronic medical record?

The U.S. Department of Health and Human Services indicated that the ________________ is a digital collection of patient's medical history.

Consumers are the primary source of information about their health history and medications. The patient-carried record (PCR) addresses this. Which of the following are potential problems associated with the PCR?

The Bush administration called for the adoption of the electronic health record (EHR) by 2014 as a means to help transform U.S. health care. Who owns the individual client record when an EHR is used?

Which of the following is a major component of the computer-based patient record (CPR) ?

Which of the following statements is true about the benefits of the electronic health record (EHR) ?

Which of the following topics must be addressed when giving a presentation to physicians on the benefits of the electronic medical record (EMR) ?

The EHR offers benefits to nurses, physicians, and other health care providers, the health care enterprise, and most importantly, the consumer. Much must be done before the benefits associated with the EHR can be realized. Which of the following is one action that has been proposed by experts?

Healthcare Information and Management Systems Society (HIMSS) has defined and described the term electronic Personal Health Record (ePHR) . Which of the following are included in the HIMSS definition and description?

Electronic medical record (EMR) result reporting and data repository components include unstructured data. Which of the following are examples of unstructured data?

Unlike other health records the _____________________is patient-centered, presenting a more-balanced view of an individual's health history.

Information in the electronic health record (EHR) may be owned by the patient or stakeholder. Which of the following about the EHR is different than the electronic medical record (EMR) ?

Which of the following are major impediments to the development of an electronic health record (EHR) ?

The computer-based patient record (CPR) is a comprehensive lifetime record that includes all information from all specialties. The Institute of Medicine (IOM) identified major components of the CPR that are considered to be the "gold standard" attributes. Which of the following are CPR components?

Which of the following are found with the electronic health record (EHR) but are not found with the computer-based patient record (CPR) ?