Chapter 6: Electronic Health Records and Applications for Managing Patient Care

Chapter 6: Electronic Health Records and Applications for Managing Patient Care

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. Which description best defines the electronic health record (EHR)?

ANS:  D

The Healthcare Information Management Systems Society (HIMSS) provides a definition of the EHR as a longitudinal electronic record of patient health information produced by encounters in one or more care settings. Every person will have a birth to death (and even postmortem) record of health-related information in electronic form from multiple sources, such as physician office visits, inpatient and outpatient hospital encounters, medications, allergies, and multiple other medical services to support care. All other answers refer to a single facility use, which is not the EHR but a potential component of the EHR.

DIF:    Cognitive Level: Remember            REF:   pp. 88-89

2. The Health Information Management Systems Society (HIMSS) developed an EMR adoption model that includes eight stages toward creating a paperless patient record environment. All application capabilities within each stage must be operational before the next stage can be achieved. Your organization has implemented systems for Stages 1 and 2. Which system should your organization consider as Stage 3 adoption?

ANS:  B

Stage 1 includes the installation of ancillaries (lab, radiology, pharmacy). Stage 2 includes clinical data repository (CDR), controlled medical vocabulary, and clinical decision support system (CDSS) and may also include document imaging and health information exchange. Stage 3 would require clinical documentation (flow sheets), CDSS (error checking), and a picture archiving system (PACS) available outside radiology.

DIF:    Cognitive Level: Apply                   REF:   p. 92

3. Which system is recommended as a method to address patient safety and reduce errors that occur during the actual administration of medicines?

ANS:  B

Bar code medication administration (BCMA) is a method used to address patient safety and reduce errors that occur during the actual administration of medicines. CPOE is used to decrease transcription errors during the ordering process. ePrescribing is also used by the physician to order the medication (not administer). The eMAR is used to document the medications that are given.

DIF:    Cognitive Level: Apply                   REF:   pp. 93-94

4. Which would be considered a niche application?

ANS:  D

Some examples of specialty department niche systems include perioperative or surgical services, maternity care, neonatal intensive care, and the emergency department. The LIS is an ancillary system. CPOE and CDSS are basic components of the EHR.

DIF:    Cognitive Level: Apply                   REF:   p. 95