ANCC Informatics Nursing 2 — Questions and Answers
Question 1: To evaluate whether a new EHR fall risk assessment tool improves patient outcomes, which study design provides the strongest evidence?
- Before-after observational study without a control group
- Expert consensus opinion survey of clinical staff
- Randomized controlled trial comparing units using the tool versus standard care (Correct answer)
- Retrospective chart review of falls in the previous year
Correct 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.
Evidence hierarchy for health IT interventions: Level I — systematic reviews/meta-analyses; Level II — RCT; Level III — quasi-experimental (before/after with control, time series); Level IV — case-control, cohort; Level V — before/after without control; Level VI — descriptive, qualitative; Level VII — expert opinion. For health IT RCT, cluster randomization by unit prevents contamination. Before-after studies common in QI cannot establish causality as other changes may explain outcome differences.
Question 2: What does CPOE stand for and what is its primary patient safety benefit?
- Clinical Protocol Order Entry — standardizes care pathways
- Computerized Physician Order Entry — eliminates handwriting-related errors and enables real-time CDS (Correct answer)
- Central Pharmacy Order Execution — automates dispensing
- Comprehensive Patient Outcome Evaluation — tracks outcomes data
Correct 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.
CPOE benefits: eliminates illegible handwriting (major source of medication errors); reduces transcription errors; enables real-time CDS (drug-drug interactions, drug-allergy checks, dose range checking, contraindications, duplicate order detection); standardizes order sets for evidence-based care; facilitates pharmacist review; creates complete audit trail. Challenges: new error types introduced (wrong patient selection, juxtaposition errors, wrong drop-down selection), alert fatigue, workflow disruption during implementation. AHRQ research: CPOE reduces medication errors 50-80% in some studies.
Question 3: What is the primary purpose of SNOMED CT in clinical documentation?
- Billing and reimbursement coding for insurance claims
- Standardized clinical terminology to enable consistent, computable clinical concepts across systems (Correct answer)
- Laboratory reference ranges and normal values
- Drug formulary management and medication ordering
Correct 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.
Key clinical terminology standards: SNOMED CT for clinical findings, procedures, body structures, organisms, and substances used for EHR clinical data; LOINC for laboratory tests and clinical observations; RxNorm for medication names; ICD-10-CM/PCS for diagnosis and procedure codes primarily for billing. SNOMED CT benefits: precise clinical documentation, enabling CDS, supporting population health queries, research, and quality reporting. Maintained by SNOMED International; US license managed by NLM.
Question 4: During EHR downtime, which nursing documentation practice is essential to ensure patient safety and data integrity when the system comes back online?
- Wait until system is restored to document all events from memory
- Use standardized paper downtime forms then back-enter all data into EHR during reconciliation (Correct answer)
- Verbally communicate all events without any documentation
- Delay all non-emergency care until EHR is restored
Correct 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.
EHR downtime management: Pre-downtime preparation includes downtime packets with pre-printed patient data snapshots and paper forms for vitals, MAR, nursing notes, and orders. During downtime: document on paper in real-time — NEVER rely on memory; perform manual medication verification; communicate critical values verbally with written backup. Post-downtime reconciliation: back-enter all paper documentation into EHR; verify accuracy; reconcile care gaps; complete medication reconciliation. Joint Commission standards require downtime policies. Unplanned events should be followed by root cause analysis.
Question 5: What does 'meaningful use' (now called 'Promoting Interoperability') of EHRs refer to?
- Using the EHR for efficient nursing documentation without wasted clicks
- A CMS incentive program requiring certified EHR technology use to improve quality, safety, and care coordination in exchange for Medicare/Medicaid payments (Correct answer)
- The hospital's internal policy for mandatory EHR training completion
- A measure of nursing staff satisfaction with the EHR system
Correct 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.
Meaningful Use established by HITECH Act (2009) had three stages: Stage 1 (2011-2012) for data capture and sharing; Stage 2 (2014) for advanced clinical processes; Stage 3 (2015+) for improved outcomes. Now called 'Promoting Interoperability' (2018+) focusing on interoperability, patient access through APIs, and e-prescribing. Non-compliance: Medicare payment reductions. Nursing informatics role: workflow redesign, staff training, optimization, quality reporting, and ensuring documentation supports measure capture.
Question 6: Which standardized nursing language is most widely used in EHRs to document nursing diagnoses, interventions, and outcomes in a computable format?
- ICD-10 nursing modification codes
- NANDA-I, NIC, and NOC (NNN taxonomy) (Correct answer)
- CPT nursing procedure codes
- SNOMED nursing subset only
Correct 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.
Standardized nursing languages recognized by ANA: NANDA-I with nursing diagnoses and defining characteristics; NIC with more than 550 nursing interventions with activities; NOC with more than 490 outcomes with indicators and Likert scale ratings. NNN taxonomy links NANDA diagnosis to NIC interventions to NOC outcomes. Benefits: enables nursing data for research, quality improvement, staffing analysis, and outcome measurement, contributing to the nursing minimum data set.
ANCC Informatics Nursing 2
To evaluate whether a new EHR fall risk assessment tool improves patient outcomes, which study design provides the strongest evidence?