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CIN: Computers, Informatics, Nursing:
doi: 10.1097/01.NCN.0000438396.60521.fc

Electronic Health Record Tools’ Support of Nurses’ Clinical Judgment and Team Communication

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GENERAL PURPOSE: To provide information on the use of electronic health record (EHR) tools to assist nurses with clinical judgment and team communication.

LEARNING OBJECTIVES: After reading this article and taking this test, you should be able to:

1. Analyze the role of EHR-generated cognitive artifacts in supporting nurses’ communication and clinical judgment.

2. Identify the degree of usefulness of various cognitive artifacts as revealed in the results of the study described in this article.

1. The authors define cognitive artifacts as

a. challenges in everyday problem solving.

b. data that result from complex intellectual processes.

c. devices designed to display information that serve as mental tools to aid the mind.

d. extraneous details and events that confound clinical systems.

2. Kossman and Scheidenhelm (2008) report a challenge with EHR-generated cognitive artifact tools is difficulty

a. finding information.

b. finding time to document data.

c. having access to computers.

d. learning the EHR system.

3. Keenan et al (2013) note that nurse-made paper tools can disrupt communication if the

a. papers are misplaced.

b. tools are not comprehensive.

c. papers are not filled out properly.

d. data are not transferred to the EHR.

4. According to Tanner’s Clinical Judgment Model, which component entails developing a grasp of the situation?

a. noticing

b. interpreting

c. responding

d. reflecting

5. What trait did Lasater (2007) link to Tanner’s “responding” dimension of clinical judgment?

a. seeking information

b. flexibility

c. making sense of the data

d. self-evaluation

6. Which EHR tool did the nurses use the most?

a. self-made work lists

b. the medication administration record (MAR)

c. the EHR problem list

d. summary notes

7. A total of 76% of nurses used what tool at least daily?

a. summary notes

b. clinical practice guidelines

c. focused assessment forms

d. care plans

8. The majority of nurses rated which tool as “extremely useful” in supporting communication?

a. self-made work lists

b. clinical practice guidelines

c. EHR problem lists

d. care plans

9. Which tool was rated by nurses as the least useful for communication?

a. EHR problem lists

b. MAR

c. summary notes

d. clinical practice guidelines

10. Which tool did the nurses rate as the most useful for supporting overall clinical judgment?

a. care plans

b. self-made work lists

c. summary notes

d. MAR

11. The tool rated the least useful for supporting overall clinical judgment was

a. clinical practice guidelines.

b. focused assessment forms.

c. MAR.

d. EHR problem lists.

12. No tool helped more than 50% of the nurses do any of the following tasks except

a. anticipate potential complications.

b. stay calm and in control.

c. identify complications early.

d. determine if a patient met outcomes.

13. The focused assessment screens helped the most nurses

a. follow up on delegated tasks.

b. adjust treatment to achieve goals.

c. recognize patterns and deviations.

d. stay calm and in control.

14. In the Interpreting dimension, the work list helped the most nurses with

a. implementing tailored interventions.

b. prioritizing patient needs.

c. following up on delegated tasks.

d. monitoring patient progress.

15. In the responding dimension, the MAR helped most nurses

a. focus assessments.

b. prompt to find more information.

c. identify complications early.

d. feel they were in control.

16. The summary note helped most nurses

a. implement tailored interventions.

b. monitor patients’ progress.

c. prioritize patient needs.

d. adjust treatment to achieve goals.

17. Summary notes were ranked as the first or second most frequently used tool by all healthcare professionals except

a. pharmacists.

b. dietitians.

c. nurses.

d. social workers.

18. The clinical guidelines were viewed only by

a. physicians.

b. pharmacists.

c. physical therapists.

d. nurses.

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