Examination: Promoting standardized nursing language using an electronic medical record system

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<ul><li><p>Examination JUNE 2006, VOL 83, NO 6</p><p>AORN JOURNAL 1345</p><p>1. Paper medical records1. allow only one staff member at a </p><p>time to access a patients chart.2. may require health care pro-</p><p>viders to flip through hun-dreds of sometimes hard-to-read documents to find the information they need.</p><p>3. may require nurses to take time from patient care to contact physicians to verify the meaning of handwritten orders.</p><p>4. can be misplaced from a chart, possibly leading to duplicate examinations or medication errors. </p><p>5. prevent medication and other treatment errors across the con-tinuum of care.</p><p>a. 1 and 3b. 2, 4, and 5c. 1, 2, 3, and 4d. 1, 2, 3, 4, and 5</p><p>2. Using an electronic medical record(EMR) system can help facilitiesmeet the following 2006 NationalPatient Safety Goals</p><p>1. accurately and completely rec-oncile medications and other treatments across the continuum of care.</p><p>2. identify performance gaps and develop professional com-petencies.</p><p>3. improve the effectiveness of communication among care-givers.</p><p>4. improve the safety of using medications.</p><p>5. oversee managed care contracts.a. 2 and 5b. 1, 3, and 4</p><p>c. 1, 2, 3, and 4d. 1, 2, 3, 4, and 5</p><p>3. Documenting nursing practiceand patient care in one universallanguagea. can contribute to nursings</p><p>autonomy.b. could intimidate other profes-</p><p>sional groups (eg, in medicine,physical therapy).</p><p>c. can improve the accuracy ofpatient identification.</p><p>4. The lack of a standard nursinglanguage </p><p>1. has delayed evolution in nursing.</p><p>2. inhibits data collection.3. hampers data comparison be- </p><p>tween institutions.4. limits the development of an </p><p>evidence-based model for nursing practice.</p><p>a. 1 and 3b. 2 and 4c. 1, 3, and 4d. 1, 2, 3, and 4</p><p>5. For clinicians, consistency ofterms supports documentationthat allows uniform collection andsubsequent analysis of data on</p><p>1. patient characteristics.2. benchmarking outcomes.3. number of patient falls.4. percentage of cases and the staff </p><p>mix for those cases.5. facility infection rates.</p><p>a. 1 and 3b. 1, 2, and 4c. 2, 3, and 5d. 1, 2, 3, 4, and 5</p><p>AORN isaccredited asa provider ofcontinuingnursing education bythe AmericanNurses CredentialingCentersCommission onAccreditation.AORN isprovider-approved bythe CaliforniaBoard ofRegisteredNursing,ProviderNumber CEP13019. Checkwith yourstate board ofnursing foracceptance ofthis activityfor relicensure.</p><p>Promoting standardized nursing language using an </p><p>electronic medical record system</p><p>ExaminationMMAANNAAGGEEMMEENNTT</p></li><li><p>JUNE 2006, VOL 83, NO 6 Examination</p><p>6. An EMR system that uses a struc-tured term set allows perioperativemanagers to a. create databases comparing clin-</p><p>ical data from a large number ofpatients.</p><p>b. generate ideas for recruitmentand retention of nursing staffmembers.</p><p>c. make informed decisions regard-ing disciplinary options for staffmembers.</p><p>7. The Perioperative Nursing Data Set(PNDS) establishes a standard nurs-ing language by using a. taxonomic structure.b. previously identified nursing care</p><p>tasks.c. the Health Insurance Portability</p><p>and Accountability Act of 1996.</p><p>8. Informatics team members at thefacility discussed in this article</p><p>1. are known as database coordi-nators.</p><p>2. maintain clear communication between different groups andunits in the health care organ-ization.</p><p>3. are integrating the PNDS into the EMR system.</p><p>a. 1b. 3</p><p>c. 1 and 2d. 1, 2, and 3</p><p>9. The end user uses the intraopera-tive PNDS documentation in theEMR system by </p><p>1. identifying a nursing diagnosis.2. selecting a diagnosis from a list </p><p>of possible diagnoses in the EMR.</p><p>3. documenting the affiliated nurs-ing interventions electronically.</p><p>4. checking a box to indicatewhether the desired outcome is met.</p><p>a. 1 and 3b. 2 and 4c. 1, 2, and 4d. 1, 2, 3, and 4</p><p>10. The main goals of the surgicalteam implementing the projectdescribed the facility in this articleinclude </p><p>1. controlling instrument costs.2. ensuring continuity of patient</p><p>care.3. improving patient outcomes.4. justifying the intraoperative pre-</p><p>sence of RNs.a. 1 and 2b. 1 and 4c. 2, 3, and 4d. 1, 2, 3, and 4</p><p>1346 AORN JOURNAL</p><p>For the fourth year, AORN offered its Grand Roundsactivity on the exhibit floor at Congress. Atten-dees received information about Grand Rounds anda questionnaire with their Congress registrationmaterials. Those who wished to participate wererequired to visit exhibitors booths to learn theanswers to a series of questions. Completed ques-tionnaires that were returned to the exhibitor regis-tration area by the last day of Congress wereentered into a drawing for complimentary registra-</p><p>tion to the 54th annual Congress in Orlando, Fla,March 11-15, 2007. </p><p>Winners of complimentary registrations are SusanNiemeyer, RN, CNOR, CRNFA, Greeley, Colo, and LoriCouzens, RN, CNOR, San Rafael, Calif. MelissaPellowski, RN, BSN, Onalaska, Wis, won the grandprize, which includes complimentary airfare to Orlandoin addition to the free Congress registration. AORNcongratulates the winners and thanks all the GrandRounds participants for making this activity a success.</p><p>Congress 2006 Grand Rounds Winners Announced</p></li><li><p>Answer Sheet JUNE 2006, VOL 83, NO 6</p><p>AORN JOURNAL 1347</p><p>lease fill out the applicationand answer form on thispage and the evaluation formon the back of this page. Tearthe page out of the Journal or</p><p>make photocopies and mail to:</p><p>AORN Customer Servicec/o Home Study Program</p><p>2170 S Parker Rd, Suite 300Denver, CO 80231-5711</p><p>or fax with credit card information to (303) 750-3212.</p><p>Additionally, please verify by signature that you have reviewed the objectives and read the </p><p>article, or you will not receive credit.</p><p>Signature ________________________</p><p>1. Record your AORN member identifi-cation number in the appropriate sec-tion below. (See your member card.)2. Completely darken the spaces thatindicate your answers to examinationquestions one through 10. Use blue orblack ink only.3. Our accrediting body requires that weverify the amount of time you requiredto complete this 1.8 contact hour (90-minute) program.__________4. Enclose fee if information is mailed.</p><p>P</p><p>AORN (ID) # _______________________________Name _____________________________________Address ___________________________________City_______________________________________ State __________ Zip ____________ Phone number______________________________RN license #________________________________ State __________________________Fee enclosed _______________________________or bill the credit card indicated MC Visa American Express DiscoverCard # ____________________________________ Expiration date</p><p>Signature _________________________________________________ (for credit card authorization)</p><p>Event #06107 Session #7275</p><p>Contact hours:1.8</p><p>Fee:Members </p><p>$9Nonmembers</p><p>$18</p><p>Programoffered </p><p>June 2006</p><p>The deadlinefor this </p><p>program isJune 30,</p><p>2009</p><p>A score of 70%correct on theexaminationis requiredfor credit. </p><p>Promoting standardized nursing language using an </p><p>electronic medical record system</p><p>Answer SheetMMAANNAAGGEEMMEENNTT</p></li><li><p>JUNE 2006, VOL 83, NO 6 Learner Evaluation</p><p>1348 AORN JOURNAL</p><p>ObjectivesTo what extent were the followingobjectives of this Home Study Programachieved?1. Discuss the advantages of electronic</p><p>medical record (EMR) systems com-pared to paper medical records.</p><p>2. Explain how EMR systems canhelp facilities meet the 2006National Patient Safety Goals.</p><p>3. Describe the advantages of a uni-versal nursing language.</p><p>4. Discuss the EMR implementationproject presented in this article.</p><p>ContentTo what extent5. did this article increase your know-</p><p>ledge of the subject matter?6. was the content clear and organized?7. did this article facilitate learning?8. were your individual objectives met?9. did the objectives relate to the over-</p><p>all purpose/goal?</p><p>Test Questions/AnswersTo what extent10.were they reflective of the content?11.were they easy to understand?12.did they address important points?</p><p>Learner Input13.Will you be able to use the infor-</p><p>mation from this Home Study inyour work setting?a. yes b. no</p><p>14.I learned of this Home Study viaa. the Journal I receive as an AORN</p><p>member.b. a Journal I obtained elsewhere.c. the AORN web site.d. the AORN Manager Resources</p><p>web page.</p><p>15.What factor most affects whetheryou take an AORN Journal HomeStudy?a. need for contact hoursb. pricec. subject matter relevant to current</p><p>positiond. number of contact hours offered</p><p>What other topics would you like to seeaddressed in a future Home StudyProgram? Would you be interested or doyou know someone who would be inter-ested in writing an article on this topic?Topic(s): _________________________________________________________________________________________________Author names and addresses: ______________________________________________________________________________</p><p>This evalua-tion is used todetermine theextent towhich thisHome StudyProgram metyour learningneeds. Ratethese itemson a scale of1 to 5.</p><p>Purpose/Goal:To educateperioperativenurses aboutimplementingan electronicmedical record that incorporates astandardized nursing language.</p><p>Promoting standardized nursing language using an </p><p>electronic medical record system</p><p>Learner EvaluationMMAANNAAGGEEMMEENNTT</p></li></ul>

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