Informatics Nursing Flashcards

To evaluate whether a new EHR fall risk assessment tool improves patient outcomes, which study design provides the strongest evidence?

Answer: Randomized controlled trial comparing units using the tool versus standard care

A randomized controlled trial (RCT) provides the highest level of evidence by controlling for confounding variables through random assignment, allowing causal inference.

What does CPOE stand for and what is its primary patient safety benefit?

Answer: Computerized Physician Order Entry — eliminates handwriting-related errors and enables real-time CDS

CPOE enables electronic medical orders, eliminating illegible handwriting and transcription errors, and enabling real-time CDS including drug interactions, allergy checks, and dosing alerts.

What is the primary purpose of SNOMED CT in clinical documentation?

Answer: Standardized clinical terminology to enable consistent, computable clinical concepts across systems

SNOMED CT is a comprehensive multilingual clinical terminology providing standardized, computable clinical concepts for documentation, semantic interoperability, and data analytics.

During EHR downtime, which nursing documentation practice is essential to ensure patient safety and data integrity when the system comes back online?

Answer: Use standardized paper downtime forms then back-enter all data into EHR during reconciliation

Effective EHR downtime management requires pre-established paper-based backup processes for documentation, followed by systematic back-entry and reconciliation when the system is restored.

What does 'meaningful use' (now called 'Promoting Interoperability') of EHRs refer to?

Answer: A CMS incentive program requiring certified EHR technology use to improve quality, safety, and care coordination in exchange for Medicare/Medicaid payments

Meaningful Use (now Promoting Interoperability under CMS) is the federal incentive program established by the HITECH Act requiring specific EHR use criteria to receive Medicare/Medicaid incentive payments and avoid payment penalties.

Which standardized nursing language is most widely used in EHRs to document nursing diagnoses, interventions, and outcomes in a computable format?

Answer: NANDA-I, NIC, and NOC (NNN taxonomy)

The NNN taxonomy — NANDA-I (nursing diagnoses), NIC (Nursing Interventions Classification), and NOC (Nursing Outcomes Classification) — is the most widely recognized standardized nursing language for documenting the nursing process.