Deck 6: Documentation of the Nutrition Care Process

Question 1

A statement regarding the patient's nutritional status at this time would be recorded in which section of the SOAP note?

A)S
B)O
C)A
D)P

Answer 1

C

Question 2

Data such as patient reports of nausea or vomiting would be recorded in which section of the SOAP note?

A)S
B)O
C)A
D)P

Answer 2

A

Question 3

Which of the following would not appear in a CBE note?

A)a flowchart
B)a standardized nutritional care plan
C)an unexpected physiological response to an intervention
D)lab findings from day 5 that were all WNL

Answer 3

D

Question 4

The PES statement is:

A)used to describe the patient's compliance to nutrition interventions.
B)a statement of the nutrition diagnosis.
C)an extension of the medical diagnosis.
D)developed by the interdisciplinary team.

Question 5

Audits, determining patient care, and legal proceedings are all uses for:

A)the medical record.
B)physician progress notes.
C)interdisciplinary team rounds.
D)DRGs.

Question 6

One of the most important goals of documentation in a medical record is:

A)to be clear and concise.
B)to develop your own method of charting.
C)to follow the ADA format.
D)to use medical abbreviations.

Question 7

Which of the following is not a step in the nutrition care process?

A)nutrition screening
B)nutrition diagnosis
C)nutrition monitoring and Evaluation
D)nutrition assessment

Question 8

Medical nutrition therapy strategies would be listed in which section of the SOAP note?

A)S
B)O
C)A
D)P

Question 9

Your patient has just had labs drawn and there is an abnormal value You would record this in which section of the SOAP note?

A)S
B)O
C)A
D)P

Question 10

Which of the following is not part of the POMR medical record?

A)data
B)progress note
C)interdisciplinary treatment plan
D)discharge summary

Question 11

The form of documentation that is organized to reflect the nutrition care process is:

A)SOAP.
B)ADIME.
C)Focus notes.
D)PIE.

Question 12

One quality improvement being made to charting is:

A)the RD documenting care in the progress notes.
B)electronic documentation.
C)restricting patient access to records.
D)changing the organization of the medical record to POMR.

Question 13

Which of the following is true about writing for the medical record?

A)You should set aside your biases.
B)Abbreviations are well interpreted by all reading your notes.
C)It is best to chart before a patient has a procedure.
D)You must use complete sentences.

Question 14

Inferences about the medical data or your observations from the patient would be interpreted in which section of the SOAP note?

A)S
B)O
C)A
D)P

Question 15

Long-term care facilities that are receiving patients from the hospital would be most interested in which portion of the medical record?

A)the progress notes
B)the teaching plan
C)the problem list
D)the discharge summary

Question 16

Which of the following is an acceptable medical abbreviation?

A)U
B)BID
C)QD
D)4.0 mL

Question 17

Of all of the genres in which dietitians express themselves, which one would be most often viewed by an interdisciplinary team?

A)brochures
B)charting
C)handouts
D)memos

Question 18

Documentation of referral to a social worker would be included in which section of the SOAP note?

A)S
B)O
C)A
D)P

Question 19

Specific standards that guide documentation in a medical record are devised by:

A)the dietitian.
B)the clinical nutrition manager.
C)accrediting agencies.
D)the physicians.

Question 20

Of all of the different styles of charting, which one is the most well known?

A)POMR
B)SOAP
C)IER
D)Focus notes

Question 21

When writing, the ethos is an important component because:

A)it allows the reader to understand the text more clearly.
B)it establishes you as the expert.
C)it describes the focus of your writing.
D)it takes into consideration the level of education of the audience.

Question 22

Case Study Multiple Choice
Your facility has recently adopted a new method of documenting in the medical record consistent with the American Dietetic Association's nutrition care process.You were trained using the SOAP method.You need to answer the following questions so that your transition to the new documentation method is smooth.
The information contained in the "S" portion of your SOAP note will now be written in which part of the ADIME note?

A)A
B)D
C)I
D)M/E

Question 23

A violation of a patient's confidentiality may take the form of:

A)discussing a patient's status with the local pharmacist.
B)discussing a patient's status with his or her physician.
C)discussing a patient's status with his/her spouse in the patient's room.
D)discussing a patient's status with physical therapist who treats the patient.

Question 24

Setting goals and recalibrating one's thinking process as part of the overall writing process can be defined as:

A)invention.
B)editing.
C)drafting.
D)revision.

Question 25

The law that assures patient confidentiality is called:

A)JCAHO.
B)ADIME.
C)HIPAA.
D)POMR.

Question 26

Case Study Multiple Choice
Your facility has recently adopted a new method of documenting in the medical record consistent with the American Dietetic Association's nutrition care process.You were trained using the SOAP method.You need to answer the following questions so that your transition to the new documentation method is smooth.
The information contained in the "O" portion of your SOAP note will now be written in which part of the ADIME note?

A)A
B)D
C)I
D)M/E

Question 27

Case Study Multiple Choice
Your facility has recently adopted a new method of documenting in the medical record consistent with the American Dietetic Association's nutrition care process.You were trained using the SOAP method.You need to answer the following questions so that your transition to the new documentation method is smooth.
When developing your PES statement, the signs and symptoms will likely come from which part of your ADIME note?

A)A
B)D
C)I
D)M/E

Question 28

Case Study Multiple Choice
Your facility has recently adopted a new method of documenting in the medical record consistent with the American Dietetic Association's nutrition care process.You were trained using the SOAP method.You need to answer the following questions so that your transition to the new documentation method is smooth.
Which of the following would be new to the RD who is transitioning to the ADIME format?

A)A
B)D
C)I
D)M/E

Question 29

Case Study Multiple Choice
Your facility has recently adopted a new method of documenting in the medical record consistent with the American Dietetic Association's nutrition care process.You were trained using the SOAP method.You need to answer the following questions so that your transition to the new documentation method is smooth.
Which section of your ADIME note will describe the parameters that you will be looking for in your follow-up to see if your nutrition diagnosis is resolved?

A)A
B)D
C)I
D)M/E

Question 30

Case Study Multiple Choice
Your facility has recently adopted a new method of documenting in the medical record consistent with the American Dietetic Association's nutrition care process.You were trained using the SOAP method.You need to answer the following questions so that your transition to the new documentation method is smooth.
The information contained in the "P" portion of your SOAP note will now be written in which part of the ADIME note?

A)A
B)D
C)I
D)M/E

Question 31

A description of ethos in writing for a medical record is:

A)the person who will be reading your writing.
B)your clinical knowledge and expertise.
C)what the text is about.
D)how the text is interpreted.