STUDY GUIDE # 11

ELECTRONIC HEALTH RECORD

Instructions: Refer to the following pages for your answers: Pages 129-131, 133 – 138 of your book in a pdf file. If
you’re using an actual book, refer to pages 155 -157, 159-164. The number before each question is just for
organization purposes because there are test items that will be merged in iStudy, thus, only then a perfect score
will be known. The answers will be entered into iStudy.
1. computer____are used for educating nursing students and clients; assessing, documenting, and testing clients’
health conditions; managing health records, communicating among health care providers and with clients; and
conducting nursing research.
2. All nurses must have a basic level of computer _literacy___ (the knowledge and ability to use computers or
technology) in order to perform their jobs.

3. It is a Quality and Safety Education in Nursing (QSEN) competency defined as “Use information and technology
to communicate, manage knowledge, mitigate error_______, and support decision making.”

4. Health informatics is the management of health care _information___, using computers.

5. Nurses should evaluate health _website____________ as they access them and assist clients in doing the same.

6. The most common types of computer systems used by nurses are _management____ information systems and
_hospital____ information systems.

7. A hospital information system (HIS) is an MIS that focuses on the types of data needed to manage __client care
activies__________ and health care organizations.

8. Nursing has benefited from the computer revolution in the form of computer-__assisted instruction___.

9. Many activities of the registered nurse involve collecting, _recording__ and using data. Computers are well suited
to assist the nurse in these functions.

10. Improvement in both clinical and nonclinical processes can occur through the uses of _Technology__ in
biomedical monitoring, communication, client safety systems, decision support, and education.

11. As a component of accreditation of schools of nursing as well as health organizations, nurses are expected to have
knowledge about the benefits and __limitation__ of technology, skills in using technology for communication and
decision making, and attitudes needed to value technology and use informatics to both support and protect clients.

12. In the typical day of a nurse providing direct client care, as much as one third of the time may be spent
_recording___ in the client’s record.

13. Additional __Time_________ is spent trying to access data about the client that may be somewhere in the
medical record or elsewhere in the health care agency.

14. Nurses need access to __standardized_______ forms, policies, and procedures.

15. Nurses need to be able to gather _broader____ client information such as length of stay for specific diagnoses.

16. There are several different types of computerized __bedside data___ entry systems.
17. Bedside data entry systems allow recording of medication___ administration, client assessments, progress notes,
care plan updating, client acuity, and accrued charges.

18. The nurse must learn how to navigate and _troubleshoot______ the device before using it at the bedside so the
client does not observe any frustration if you experience difficulties.

19. Nurse must always _address________ the client before using the computer. Explain what the computer is for and
how the patient’s confidentiality is assured.
An HER can improve health care in at least four ways: (refers to 20-23)
20. Constant_availability__ of client health information across the life span.

21. Ability to monitor _quality__.

22. _access____ to warehouse (stored) data.

23. Ability for clients to share in knowledge and _activities___influencing their own health.
34. Because of the way computers provide access to EHRs, providers can easily retrieve specific data such as
_trends______ in vital signs, immunization records, and current problems.
35. The system can be designed to __warm provider___ about conflicting medications or client parameters that
indicate dangerous conditions.
36. Sophisticated systems allow replay of audio, graphic, or video data for comparison with current status. Challenges
with reading handwriting are eliminated and all text is _searchable_________________.
37. There are several areas of concern with EHRs. Maintaining the privacy and _security___ is a significant issue.
38. One way in which computers can protect data is by user authentication via ___passwords___ or biometric
identifiers – only those persons who have _legitimate need_____________ to access the data receive the
password.
39. One of the roles of the nurse informaticist, an expert who combines computer, information and nursing sciences, is
to develop _policies_______ and procedures that promote effective and secure use of computerized records by
nurses and other health care professionals.
40. Personal Health Record is an electronic document that contains the client’s medical, personal, and health
information but is __controlled____ by the client, rather than the health care provider.
41. A significant advantage of a PHR stored in a commonly accessible format is that clients can transport and give the
__information_______________ to any care provider they wish, whenever necessary.
42. Many different computer systems exist. Some simple alarms that appear when medical orders _conflict___ with
another aspect of the client’s situation.
43. Other systems provide step-by-step online tools to assist emergency department nurses in determining which
clients should receive the most__immidiate___ attention or are comprehensive programs integrated with a
system-wide EHR.
44. For nursing to be recognized for the value it adds to client well-being, research that shows client
_improvement___________ must be based on accepted standards.
45. This necessitates the use of common, consistent, clear, and rule based __standards_____________.
46. Once EHR has been established, the nurse can retrieve and display a client’s _physiological___ parameters across
time.
47. Telemedicine or telehealth uses technology to transmit_electronic___ data about clients to persons at distant
locations.
48. Computers are used extensively for scheduling. Client appointments can be easily entered or
_changed____________.
49. Each practice needs to keep track of procedures health care workers perform, client diagnoses, and time spent with
clients so that billing can be __accurate____________.
50. In keeping with HIPAA regulations, electronic data interchange (EDI) protocols are used to maximize privacy and
minimize the chances of inappropriate sharing of _confidential___ client data.
51. With managed care, information tracking is also aimed at determining _trends____ in health problems and the
need for providers with specific skills.
52. The use of computerized databases filled with unique codes for each medication, medical and nursing diagnosis,
treatment, and supply allows for accurate and timely management____ of these data.
53. Nurses who visit clients in their homes are using _notebook_____________ computer systems to record
assessments and transmit data to the main office.
54. Case managers must be able to track a group pf client – the _case load_____.
55. A growing number of health care providers are using video _monitoring____ to check in on clients.
56. _Administrators______ can use these human resources databases to communicate with employees, examine
staffing patterns, and create budget projections.
57. _Medical records__ must be maintained for many years in case the data are needed for client care or research.
58. Storage of paper documentation can be cumbersome and __costly____.
59. Although it is expensive to store records, the cost of human __time______ and energy plus inefficiency in
accessing the contents is even more expensive.
60. Computerized__ records increase the ability to demonstrate the value of nursing care. Computerized
61. Security devices such as readers that can scan identification cards, bar codes, or magnetic strips permit only
__authorized____ personnel to enter client or private areas.
62. Computers can also affect cost savings by reducing the _derical services__ time needed for accounts payable and
receivable.
63. Quality_____ is considered a process and not an end point. Applying this perspective, computerized systems are
ideal for taking a snapshot view of the institution’s quality indices at any time.
64. The Joint Commission has mandated that hospitals have online mechanisms to monitor quality indicators, so as to
reduce the difficulty and time involved in the __accreditation ____ process.
65. Health care agencies must maintain databases of policies and procedures, standards of care, and employee
accomplishment of The Joint Commission _requirments____ such as continuing education and in-service
trainings.
th
Reference: Berman, A. & Synder, S. (2016) Kozier & Erb’s Fundamentals of Nursing. 10 ed. Pearson
Education, Inc.

Note: Please remember that your answers will be encoded in iStudy once the folder for this topic is open.