Deck 6: Documentation of the Nutrition Care Process

Question 1

A dietitian is documenting a list of the patient's medications and supplements using the ADIME format. Which section of the charting would this information fall under?​

A) ​Assessment
B) ​Diagnosis
C) ​Monitoring
D) ​Evaluation
E) ​Inference

Answer 1

A

Question 2

The "I" in ADIME charting stands for:​

A) ​ideal.
B) ​impaired.
C) ​identification.
D) ​intervention
E) ​interaction.

Answer 2

D

Question 3

Which type of information would be documented under the "S" portion of the SOAP format?​

A) ​the patient's age
B) ​medical diagnosis
C) ​nutrition therapy recommendations
D) ​the patient's vital signs
E) ​psychosocial factors affecting care

Answer 3

E

Question 4

The nutrition care process consists of four steps: nutrition assessment, intervention, evaluation/monitoring, and:​

A) ​diagnosis.
B) ​judgment.
C) ​analysis.
D) ​conclusion.
E) ​investigation.

Question 5

A patient reports that he is nauseated and has vomited two times. This information would be included in which part of the SOAP note?​

A) ​Subjective
B) ​Objective
C) ​Assessment
D) ​Analysis
E) ​Plan

Question 6

Which describes a function of the patient's medical chart?​

A) ​Communicating information between medical professionals and the public
B) ​Evaluating medical care for the client's family
C) ​Upholding the Joint Commission's standards
D) ​Keeping a record of what has been done for the patient
E) ​Supporting the need for funding the non-profit facility

Question 7

Which information is included in the charting by exception (CBE) method?​

A) ​the patient's height, weight, and BMI
B) ​estimated energy requirements
C) ​the nutritional care plan
D) ​dietary assessment data
E) ​results of the physical exam

Question 8

The organizational structure or format in which the nutrition diagnosis is written is called the:​

A) ​SOAP note.
B) ​PES.
C) ​focus notes.
D) ​nutrition diagnosis.
E) ​progress notes.

Question 9

Which action would be involved with bracketing biases when charting?​

A) ​Getting rid of personal preferences and values
B) ​Describing information that is subjective to self 
C) ​Imagining how an unbiased professional would respond
D) ​Recording feelings and responses to the patient's behavior
E) ​Documenting personal discussions by placing a bracket around the words

Question 10

A nutrition practitioner has just made an error while writing in a chart. Which is the best method of correcting the situation?

A) ​Remove the page from the chart and start over
B) ​Draw a line through the error and initial it
C) ​Use correction fluid and write over it
D) ​Scribble through the error and initial it
E) ​Use red ink to write "error" and initial it

Question 11

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

A) ​to be clear and concise.
B) ​to follow ADA format.
C) ​to develop a new method of charting.
D) ​to use medical abbreviations.
E) ​to demonstrate knowledge of medicine and dietetics.

Question 12

When charting about a procedure performed on a patient, when should the nutrition practitioner chart the information?​

A) ​just before the procedure
B) ​just after the procedure
C) ​the day after the procedure
D) ​only when there are significant results
E) ​before the patient is discharged

Question 13

Which describes a section of the problem-oriented medical record (POMR)?​

A) ​progress notes
B) ​research results
C) ​billing statements
D) ​reimbursement policies
E) ​facility medical procedures

Question 14

Which would be considered an acceptable medical abbreviation?​

A) QD
B) ​U
C) ​cc
D) ​mmHg
E) ​IU

Question 15

Which charting format consists of a combination and reduction of the SOAP and IER formats?​

A) ​ADIME
B) ​IEP
C) ​PIE notes
D) ​ISFP
E) ​Focus notes

Question 16

A record of an individual's care that provides health information from all clinicians that provide care and is designed to follow the patient wherever they receive health care is known as the:​

A) ​electronic medical record (EMR).
B) ​medical chart.
C) ​electronic health record (EHR).
D) ​patient register.
E) ​personal health record (PHR).

Question 17

A physician has ordered 6U of insulin for a patient. Which would be the correct method of writing this order instead?​

A) ​6 Un
B) ​Six U
C) ​Six units
D) ​6 units
E) ​6 ut

Question 18

Which information would go under the "I" section of an IER note?​

A) ​laboratory data
B) ​record of intake and output
C) ​dietary assessment data
D) ​plans for follow-up
E) ​nutrition education

Question 19

The patient's medical record contains CPT codes for documentation. CPT stands for:​

A) ​Computerized Policies and Training
B) ​Current Procedural Terminology
C) ​Calculated Programs and Technology
D) ​Consistent Prospective Testing
E) ​Copied Preferences and Testimonies

Question 20

Which abbreviation is on the Joint Commission's official "Do Not Use" list?​

A) ​mg
B) ​IU
C) ​mL
D) ​mEq
E) ​kg

Question 21

Which factor is essential to keep in mind while documenting in a patient's chart?

A) ​Include less information, rather than too much
B) ​Only record assumptions at the end of documentation
C) ​Add a signature only with written documentation, not electronic
D) ​Avoid abbreviations unless it is clear that anyone can understand them
E) ​Only chart what others see as significant

Question 22

The information written in the "S" portion of the SOAP format would now be written in which portion of the ADIME note?​

A) ​A
B) ​D
C) ​I
D) ​M
E) ​E

Question 23

Levels of discourse are generally described as:

A) ​the reasons for writing the text.
B) ​norms, ideas, organization, and grammar.
C) ​the readers to whom the writing is directed.
D) ​styles, lettering, and fonts.
E) ​the characters and settings the writing is about.

Question 24

The ethos is an important component of writing because:​

A) ​it allows the reader to understand the text more fully.
B) ​it establishes the nutrition professional as the expert.
C) ​it describes the focus of the writing.
D) ​it considers the education level of the audience.
E) ​it documents information for legal purposes.

Question 25

Which constitutes a goal of the Health Insurance Portability and Accountability Act (HIPAA)?​

A) ​Prevent the inappropriate use of protected health information
B) ​Prevent communication between financial institutions related to patient billing
C) ​Ensure that insurance companies are reimbursing appropriate amounts
D) ​Guarantee the safety of the patient's chart between admission and discharge
E) ​Ensure that the patient's chart is correctly transcribed into an electronic health record

Question 26

Which best describes writing processes?

A) ​A universal contextual framework
B) ​Different levels on which to focus attention
C) ​The organization of different sections of written work
D) ​The cognitive processes and stages of writing
E) ​An ability to choose the appropriate words

Question 27

Which genre written by a clinical dietitian would most likely be viewed by other members of the interdisciplinary team?​

A) ​brochures
B) ​memos
C) ​charts
D) ​handouts
E) ​pamphlets

Question 28

When describing the steps of the writing process, which would be considered the first step?​

A) ​invention
B) ​editing
C) ​drafting
D) ​sentence generation
E) ​revision

Question 29

The personality or voice that comes through the text and characterizes the writer for the reader is known as the:

A) ​spirit.
B) ​nature.
C) ​ethos.
D) ​temperament.
E) ​philosophy.

Question 30

Each context of writing contains four elements: the subject matter, the ethos, the purpose, and:

A) ​the language.
B) ​the publication.
C) ​the cognitive response.
D) ​the objective information.
E) ​the audience.

Question 31

After interviewing a patient, the dietitian describes why he is at nutritional risk. This information should be recorded in which part of ADIME charting?​

A) ​Assessment
B) ​Diagnosis
C) ​Intervention
D) ​Monitoring 
E) ​Evaluation

Question 32

The information contained in the "O" portion of the SOAP note would now be written in which part of the ADIME note?​

A) ​A
B) ​D
C) ​I
D) ​M
E) ​E

Question 33

A patient has developed a pressure ulcer from lying in bed. This information should be documented in which part of ADIME charting?​

A) ​Assessment
B) ​Diagnosis
C) ​Intervention
D) ​Monitoring
E) ​Evaluation

Question 34

A dietitian is documenting information in a patient's chart. She writes an asterisk and then explains the information further in the comments section of the chart. Which type of documentation format is the dietitian most likely using?

A) ​SOAP format
B) ​PIE notes
C) ​charting by exception
D) ​focus notes
E) ​ADIME format

Question 35

The information from the SOAP note is consolidated into three sections: writing the patient's data, the nutritionist's interventions, and the patient's response to the interventions. This process most likely reflects which type of charting?​

A) ​CBE
B) ​PIE notes
C) ​IER format
D) ​focus notes
E) ​IEP format

Question 36

The overall movement in charting over the last decade has been toward:​

A) ​increasing the size of the medical record.
B) ​changing charting from SOAP format to ADIME.
C) ​decreasing the size of the medical record.
D) ​requiring workers to document more information.
E) ​eliminating the need for the medical record.

Question 37

Which best describes the process of pre-writing?​

A) ​recalibrating thinking
B) ​setting goals
C) ​planning the text
D) ​making minor corrections
E) ​eliminating unnecessary material

Question 38

The "P" in PIE notes stands for:​

A) ​procedure.
B) ​plan.
C) ​policy.
D) ​problem
E) ​patient.

Question 39

Which situation would be considered a violation of a patient's right to confidentiality?​

A) ​Reviewing the patient's care plan with his physician
B) ​Discussing the patient's condition with the physical therapist involved in the case
C) ​Talking about medications while the patient's spouse is in the room
D) ​Discussing the patient's status with a local pharmacist
E) ​Explaining the goals of treatment for the patient with his nurse

Question 40

A dietitian must record a patient's nutrition information in his chart, and she is waiting for the nurse to finish her notes. What guideline must the dietitian consider when she gets the chart and starts her own documentation?

A) ​Review what the nurse wrote and write the same information in her own words
B) ​Leave a small amount of white space after the nurse's writing to add information later
C) ​Ask the nurse to document the nutrition information as well
D) ​Write a signature after the nursing information and the nutrition information
E) ​Write clearly so that the nurse or anyone else reading the chart can understand the information

Question 41

Each state's licensing agency, as well as _______________, requires that all health care facilities monitor, evaluate, and seek ways to improve the quality of care for their patients.

Question 42

The _______________ section of ADIME charting is where the actual PES statements are listed and prioritized.

Question 43

The Academy of Nutrition and Dietetics has promoted the use of the _______________ format because it mirrors the steps of the nutrition care process.

Question 44

The label "SOAP" refers to the four sections of each entry in the medical chart: subjective data, _______________, assessment, and plan.

Question 45

Clients frequently request copies of their medical records, but they do not have the right to read those records.

Question 46

Health professionals probably ought to write even more than they do because keeping personal notes in addition to required documentation of nutrition care provides greater opportunities for insights.

Question 47

The Joint Commission recommends that certain abbreviations not be used because they are more likely to contribute to _______________.

Question 48

Clear, concise wording in the medical record, using terminology consistent with the _______________, will facilitate reimbursement for services.

Question 49

The actual process of writing is usually always linear.

Question 50

The driving forces that impact medical record keeping include accrediting agencies for health care facilities, continuous quality improvement programs, and insurance reimbursement for medical care.

Question 51

The _______________ is defined as: "an application environment composed of the clinical data repository, clinical decision support, controlled medical vocabulary, order entry, computerized provider order entry, pharmacy, and clinical documentation applications."​

Question 52

A record of an individual's care that provides health information from all clinicians that provide care for that individual and is designed to follow the patient wherever they receive health care is known as the _______________​

Question 53

_______________ include patient information or data collected from the patient or caregiver.

Question 54

The data in the EMR is the legal record of what happened to the patient during his or her encounter with the care delivery organization and is owned by the patient.

Question 55

Steps to ensure accuracy of the medical record include the use of standard language and medical abbreviations.

Question 56

Each state's licensing agency requires that all health care facilities monitor, evaluate, and seek ways to improve the quality of care for their patients.

Question 57

While editing, successful writers wait to make editing changes to a text until revision is complete.

Question 58

The rhetorical norms of writing are the different levels of writing on which one can focus attention.

Question 59

The data portion of problem-oriented medical record is a list of expected outcomes and plans for further data collection.

Question 60

The POMR is divided into five parts: data, problem list, care plan, progress notes, and _______________.

Question 61

List the three important areas of writing that are necessary for communication that must be understood for all writers.

Question 62

Differences in the writing of different communities --different disciplines, different workplaces -- coalesce into what are referred to as _______________.

Question 63

The levels of _______________ include the different levels of writing on which one can focus attention.

Question 64

List the basic functions of writing for both personal and professional situations.

Question 65

Discuss each of the following steps in the writing process: prewriting, drafting, revision, editing.

Question 66

All writing involves subject matter, a purpose, an audience, and the writer's _______________.

Question 67

Discuss the purpose and give an example of charting by exception in the patient's medical record.

Question 68

When charting, remember that medical charts are _______________ documents as well as medical documents.

Question 69

A set of readers to whom the text is directed is known as the _______________.

Question 70

Describe the importance of developing a personal medical notebook and note its use, advantages, and disadvantages.

Question 71

Discuss possible options for research and publication for the nutrition professional beyond writing patient instructions.

Question 72

List each component of the following acronyms: SOAP, ADIME, IER.

Question 73

_______________ involves whatever it is that the writer does before actually writing.

Question 74

Describe the parameters of the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

Question 75

List three examples of guidelines for charting that were stated in the text.

Question 76

When referring to a patient while charting, use the term "patient" or "_______________," and not his or her name.

Question 77

The federal U.S. law that assures patients of the confidentiality of their medical information is the Health Insurance Portability and _______________ Act of 1996, or HIPAA.

Question 78

Using IER notes, _______________ refers to the assessment part of SOAP, the diagnosis and evaluation based on the data gathered.

Question 79

When using the charting by exception method, a(n) _______________ indicates an abnormal finding on an assessment or an abnormal response to an intervention.

Question 80

Name the elements involved with every rhetorical norm.