PNVN 1811 – Chapter 3 NF Comprehension, 2026 – Study
guide and course material
Chart - correct answer ✔✔ Also known as the health care record.
A legal record that is used to meet the many demands of the health, accreditation, medical
insurance, and legal systems.
Charting - correct answer ✔✔ Also known as documenting and recording.
Involves recording the interventions carried out to meet the patient's needs. Good quality
documenting reflects nursing process.
Assessment - correct answer ✔✔ Portion of the nursing process that checks patient's
physiological status, functional status, knowledge, psycho-social well-being, family, and safety.
Usually interviews from patient are done, as well as a history check and physical examination,
lab work and medication records are viewed as well.
Diagnosis - correct answer ✔✔ Portion of the nursing process that checks a patient's potential
ailments based on assessments.
Plan of Care - correct answer ✔✔ Portion of the nursing process that defines a goal that the
individual will accomplish. Involves the patient's care plan, their projected length of stay, the
standards of care, the admission assessment data, and staff reports.
Implementation - correct answer ✔✔ Portion of the nursing process that uses progress notes
and patient rounds and care to determine the progress the individual/patient is making to
achieving goals set in the plan of care.
, Evaluation - correct answer ✔✔ Portion of the nursing process that uses family interviews,
physical assessment, staff and progress reports, diagnostic tests, and flow sheets to determine
whether the treatment of the plan of care was effective.
Auditor - correct answer ✔✔ An individual appointed to examine patient charts and health
records to assess the quality of care. They check to see if all ordered care was charted as given
and whether responses to care plan items were noted.
Peer Review - correct answer ✔✔ A system or individual that appraises an individual nurse's
practice, education, and research.
Quality Assurance Assessment Improvement - correct answer ✔✔ Also known as QAPI
It is an audit in health care that evaluates services provided and the results achieved compared
with accepted standards.
Diagnosis Related Groups - correct answer ✔✔ Also known as DRG
A system used by Medicare/Medicaid that classifies patients by age, diagnosis, surgical
procedure, and other categories to predict hospital resources such as length of stay, resulting in
a fixed payment.
Nursing Notes - correct answer ✔✔ Form in a patient's chart where nurses record observations,
the care given, and patient responses.
Electronic Health Record - correct answer ✔✔ Also known as EHR
guide and course material
Chart - correct answer ✔✔ Also known as the health care record.
A legal record that is used to meet the many demands of the health, accreditation, medical
insurance, and legal systems.
Charting - correct answer ✔✔ Also known as documenting and recording.
Involves recording the interventions carried out to meet the patient's needs. Good quality
documenting reflects nursing process.
Assessment - correct answer ✔✔ Portion of the nursing process that checks patient's
physiological status, functional status, knowledge, psycho-social well-being, family, and safety.
Usually interviews from patient are done, as well as a history check and physical examination,
lab work and medication records are viewed as well.
Diagnosis - correct answer ✔✔ Portion of the nursing process that checks a patient's potential
ailments based on assessments.
Plan of Care - correct answer ✔✔ Portion of the nursing process that defines a goal that the
individual will accomplish. Involves the patient's care plan, their projected length of stay, the
standards of care, the admission assessment data, and staff reports.
Implementation - correct answer ✔✔ Portion of the nursing process that uses progress notes
and patient rounds and care to determine the progress the individual/patient is making to
achieving goals set in the plan of care.
, Evaluation - correct answer ✔✔ Portion of the nursing process that uses family interviews,
physical assessment, staff and progress reports, diagnostic tests, and flow sheets to determine
whether the treatment of the plan of care was effective.
Auditor - correct answer ✔✔ An individual appointed to examine patient charts and health
records to assess the quality of care. They check to see if all ordered care was charted as given
and whether responses to care plan items were noted.
Peer Review - correct answer ✔✔ A system or individual that appraises an individual nurse's
practice, education, and research.
Quality Assurance Assessment Improvement - correct answer ✔✔ Also known as QAPI
It is an audit in health care that evaluates services provided and the results achieved compared
with accepted standards.
Diagnosis Related Groups - correct answer ✔✔ Also known as DRG
A system used by Medicare/Medicaid that classifies patients by age, diagnosis, surgical
procedure, and other categories to predict hospital resources such as length of stay, resulting in
a fixed payment.
Nursing Notes - correct answer ✔✔ Form in a patient's chart where nurses record observations,
the care given, and patient responses.
Electronic Health Record - correct answer ✔✔ Also known as EHR
