Data Standards

Question 1

data that are used to describe other data.

Answer 1

Meta Data

Question 2

often accessed by search engines to determine which files to access.

Answer 2

Meta Data

Question 3

define the electronic health record (EHR)as a “secure, real-time, point-of-care, patient-centric information resource for clinicians.”

Answer 3

Healthcare information and management systems society

Question 4

have been developed to allow exchange of health information among different health care providers in a specified area, region, or system.

Answer 4

Health information exchanges (HIEs)

Question 5

are developed to improve the delivery of health care. RHIPs cover all aspects of health care, including risk factors, diagnosis, treatment, disability, and social/mental factors, as well as all delivery systems, including hospitals, clinics, and individual practitioners.

Answer 5

Regional Health improvement plans (RHIPs)

Question 6

three classification systems used in nursing informatics

Answer 6

NANDA-I
Nursing Interventions Classification (NIC)
Nursing Outcomes Classification (NOC)

Question 7

provides uniform terms for patient problems that may occur during an operation.

Answer 7

The perioperative nursing data set (PNDS)

Question 8

Includes diagnostic and intervention components.

Answer 8

The perioperative nursing data set (PNDS)

Question 9

Provides documentation standards framework.

Answer 9

The perioperative nursing data set (PNDS)

Question 10

comprehensive collection of clinical terms.

Answer 10

SNOMED CT

Question 11

data dictionary designed to provide a standard set of terms (capturing clinical data) for inclusion in healthcare information systems.

Answer 11

Patient Care Data Set (PCDS)

Question 12

This system was formerly known as Home Health Care Classification (HHCC)

Answer 12

Clinical Care Classification (CCC)

Question 13

The system uses two major subsets of information:

Answer 13

Clinical Care Classification (CCC)

Question 14

The terms used in the specific diagnosis and outcomes of a disease state.

Answer 14

Diagnoses and outcomes

Question 15

For a given disease state, the appropriate interventions and actions.

Answer 15

Interventions and actions

Question 16

There are 21 “Care Components” which classify care over a wide range of factors such as functional, physiological, and psychological.

Answer 16

Clinical Care Classification (CCC)

Question 17

Uses a Problem Classification Scheme (assessment). This scheme allows for evaluating the condition of the patient.

Answer 17

Omaha System

Question 18

prescribes the appropriate interventions to treat the problem (or disease state).

Answer 18

The Intervention Scheme

Question 19

This database of terms is used primarily for laboratory results

Answer 19

Logical Observation Identifiers Names and Codes (LOINC)

Question 20

provides uniform terms for nursing data.

Answer 20

International Classification for Nursing Practice (ICNP)

Question 21

the goal is to create a system in which data can be examined and transmitted to other computers systems in a recognizable way.

Answer 21

International Classification for Nursing Practice (ICNP)

Question 22

Categories for diagnosis, interventions, and outcomes.

Answer 22

International Classification for Nursing Practice (ICNP)

Question 23

a dynamic collection of standardized terms related to nursing.

Answer 23

Nursing Management Minimum Data Set (NMMDS)

Question 24

The goal is to create terms that will allow data to be compared across a wide swath of computer systems.

Answer 24

Nursing Management Minimum Data Set (NMMDS)

Question 25

were developed by the American Medical Association and used to define those licensed to provide services as well as medical and surgical treatments, diagnostics, and procedures.

Answer 25

Current procedural terminology (CPT) codes

Question 26

usually updated each October with revisions (additions, deletions) to coding.

Answer 26

CPT codes

Question 27

mandated by both the Centers for Medicaid and Medicare and the Health Insurance Portability and Accountability Act (HIPAA) to provide a uniform language and to aid research.

Answer 27

CPT codes use

Question 28

These codes are used primarily for billing purposes for insurance (public and private).

Answer 28

CPT codes

Question 29

codes are used to identify a procedure or service.

Answer 29

Category I

Question 30

codes are used to identify performance measures, including diagnostic procedures.

Answer 30

Category II

Question 31

codes identify temporary codes for technology and data collection.

Answer 31

Category III

Question 32

developed by the World Health Organization to acquire worldwide morbidity and mortality data, are used to code for diagnoses.

Answer 32

The International Classification of Disease (ICD) codes

Question 33

diagnoses were used by all providers, but were used only for inpatients;

Answer 33

ICD-9 codes

Question 34

is an HL7 workgroup that develops standard protocols for the sharing of information among applications at the point of care through context management.

Answer 34

Clinical Context Object Workgroup(CCOW)

Question 35

defines the standards that allow interoperability and focuses on the use of technology neutral architecture and widely used computer technology.

Answer 35

CCOW

Question 36

works in collaboration with the HL7 Security Workgroup to ensure protection of data.

Answer 36

CCOW

Question 37

a nongovernmental organization, encompasses a network of standard institutes, public and private, in 164 countries and develops and publishes voluntary international standards based on consensus.

Answer 37

The International Organization for Standardization (ISO)

Question 38

working toward implementing standards in the area of medical informatics.

Answer 38

The National Institutes of Health(NIH)

Question 39

There are two major standards associated with nursing informatics

Answer 39

The Institute of Electrical and Electronic Engineers (IEEE) & The National Electrical Manufacturers Association

Question 40

developed the P1073 Medical Information Bus (MIB) standards to aid in the transfer of information between patient medical devices and the hospital’s mainframe computer system.

Answer 40

The Institute of Electrical and Electronic Engineers (IEEE)

Question 41

created Digital Imaging and Communications in Medicine (DICOM)

Answer 41

National Electrical Manufacturers Association and the American College of Radiologists

Question 42

used in association with biomedical images and image-related information.

Answer 42

Digital Imaging and Communications in Medicine

Question 43

One of the largest standards development organizations

Answer 43

the American Society for Testing and Materials (ASTM).

Question 44

create standard methods for testing materials and procedural testing standards for different industries. F

Answer 44

role of the ASTM

Question 45

an international standard developing organization that sets standards used in the sharing, retrieval, exchange, and integration of electronic health information (clinical and administrative) among different healthcare computer systems.

Answer 45

Health Level 7(HL7)

Question 46

developed standards regarding functions needed in an EHR: direct care, supportive (administrative, financial), and information infrastructure (interoperability, security, workflow).

Answer 46

HL7

Question 47

There are seven categories of standards for HL7:

Answer 47

primary, foundational, clinical and administrative domains, EHR profiles, implementation guides, rule and references, and education and awareness.

Question 48

a standard for data formats and a web-based application programming interface (API) to facilitate the exchange of EHRs among healthcare providers.

Answer 48

fast healthcare interoperability resources (FHIR)

Question 49

allows healthcare organizations to collect real-time data

Answer 49

fast healthcare interoperability resources (FHIR)