PPNC Module 1 Study Exam Questions
& Answers 2024/2025
Documentation - ANSWERSact of recording client assessments and care in written or electronic form
Purpose of written record - ANSWERScommunication
continuity of care
QI
planning and evaluation of client outcomes
legal record
professional standards
reimbursement and utilization review
education and research
importance of standardized language - ANSWERS-make nursing visible
-support nursing research
-provide standardized terminology to use in EHR systems
NANDA vs NIC vs NOC - ANSWERSNANDA-I: for nursing diagnoses
NIC: for interventions
NOC: for patient outcomes
Organization of documentation systems: source-oriented system: - ANSWERS-disciplines document in
separate sections of the chart
-contains a variety of sections
-data scattered; may lead to fragmentation
advantage: you can easily find the health care provided by each discipline
, disadvantagE: data is scattered throughout clients record. especially difficult to track treatments and
client outcomes
Organization of documentation systems: problem-oriented system - ANSWERS-organized around client
problems
-four components: database, problem list, plan of care, progress notes
-promotes greater collaboration
AdvantagE: common problem list, easy to monitor clients progress, each discipline has ready access to
the findings, encourages greater collaboration
Organization of documentation systems: charting by exception - ANSWERS-only significant findings
documented
-uses preprinted flow sheets
- reduces amount of time spent on documentation
- can lead to omission of information and errors in care
key point: assumes that all standards have been met and the client has responded normally, unless
separate entry is made. each flow sheet has entries for expected aspects of care and thus can vary by
speciality of diagnosis
advantagE: reduces amount of time spent on documentation, reduces repetitive charting, easy to read
disadvantage: omissions of pertinent information. omissions may result from disagreement over what
constitutes as significant
Electronic health record - ANSWERSrecords that are entered via computer. combine source and problem
oriented record styles. source oriented is out common
advantage: enhanced communication and collaboration, time saving, improved quality of care
disadvantagE: expensive, downtime
Narrative charting - ANSWERS"story" of care in chronological format
& Answers 2024/2025
Documentation - ANSWERSact of recording client assessments and care in written or electronic form
Purpose of written record - ANSWERScommunication
continuity of care
QI
planning and evaluation of client outcomes
legal record
professional standards
reimbursement and utilization review
education and research
importance of standardized language - ANSWERS-make nursing visible
-support nursing research
-provide standardized terminology to use in EHR systems
NANDA vs NIC vs NOC - ANSWERSNANDA-I: for nursing diagnoses
NIC: for interventions
NOC: for patient outcomes
Organization of documentation systems: source-oriented system: - ANSWERS-disciplines document in
separate sections of the chart
-contains a variety of sections
-data scattered; may lead to fragmentation
advantage: you can easily find the health care provided by each discipline
, disadvantagE: data is scattered throughout clients record. especially difficult to track treatments and
client outcomes
Organization of documentation systems: problem-oriented system - ANSWERS-organized around client
problems
-four components: database, problem list, plan of care, progress notes
-promotes greater collaboration
AdvantagE: common problem list, easy to monitor clients progress, each discipline has ready access to
the findings, encourages greater collaboration
Organization of documentation systems: charting by exception - ANSWERS-only significant findings
documented
-uses preprinted flow sheets
- reduces amount of time spent on documentation
- can lead to omission of information and errors in care
key point: assumes that all standards have been met and the client has responded normally, unless
separate entry is made. each flow sheet has entries for expected aspects of care and thus can vary by
speciality of diagnosis
advantagE: reduces amount of time spent on documentation, reduces repetitive charting, easy to read
disadvantage: omissions of pertinent information. omissions may result from disagreement over what
constitutes as significant
Electronic health record - ANSWERSrecords that are entered via computer. combine source and problem
oriented record styles. source oriented is out common
advantage: enhanced communication and collaboration, time saving, improved quality of care
disadvantagE: expensive, downtime
Narrative charting - ANSWERS"story" of care in chronological format
