Which of the following supports the automation of nursing documentation? Standard Text: Select all that apply
1. The use of standardized nursing languages (SNLs) accepted by the American Nurses Association
2. The use of a SOAP note in narrative form to support assessment of client cardiopulmonary system
3. The use of interventions such as "turn, cough, and deep breathe" as determined by the Nursing Interventions Classifications (NIC)
4. The use of client-specific charting by exception, addressing only exceptions to normal
5. The use of nursing diagnoses such as "Alteration of Comfort" as defined by the North American Nursing Diagnosis Association (NANDA)
1,3,5
Rationale: Standardized nursing languages, including NANDA and NIC (also Nursing Outcomes Classification, (NOC)), support automation of nursing documentation so that comparisons among data may be made. These remove the ambiguity of meaning found in other documentation systems. The SOAP note and the charting by exception choices are not standardized and do not support the automation of nursing documentation.
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