Question 1

When should the nutrition practitioner begin charting information about a procedure performed on a patient?

Accepted Answer

The nutrition practitioner should begin charting information about a procedure performed on a patient just after the procedure in order to have accurate and up-to-date information in the medical record. Waiting until the day after the procedure or until discharge could result in missing important details and potentially compromising patient care. Starting at the time of admission could be too early if the procedure hasn't been scheduled yet, and starting just before discharge could result in incomplete information.

Question 2

A nutrition practitioner takes an X-ray of a patient's right leg that is swollen. Which of the following sections of the SOAP note will have this information?

Accepted Answer

The X-ray of the patient's swollen right leg is an objective observation and will therefore be noted in the objective data section of the SOAP note.

Question 3

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

Accepted Answer

The "S" in SOAP stands for "Subjective," which includes information reported by the patient, such as psychosocial factors affecting care.

Question 4

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

Accepted Answer

The standard abbreviation for insulin units is "U" and the correct way to express the order is "6 units."

Question 5

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

Accepted Answer

The format for writing a nutrition diagnosis is called the PES statement, which stands for Problem, Etiology, and Signs/Symptoms. This format is used to clearly identify the problem, its underlying cause, and the evidence that supports the diagnosis. The other options listed are common types of medical notes but are not specifically related to nutrition diagnosis.

Question 6

The "I" in ADIME charting stands for:

Accepted Answer

The "I" in ADIME charting stands for "Intervention." ADIME is an acronym used in nutrition and dietetics for Assessment, Diagnosis, Intervention, Monitoring, and Evaluation.

Question 7

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

Accepted Answer

The patient's report of feeling nauseated and vomiting is subjective information because it is based on the patient's personal experience and cannot be directly measured or observed by the healthcare provider.

Question 8

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

Accepted Answer

The fourth step in the nutrition care process is diagnosis, in which the nutrition professional identifies and labels the problem(s) that were identified during assessment. This step leads to the development of a nutrition care plan in the next step of intervention.

Question 9

The nutrition practitioner made an error while writing in a chart. What is the best method to correct the error?

Accepted Answer

Drawing a horizontal line, writing "error" above it, and initialing it is the correct method for correcting an error in a chart. This ensures that the original information is still visible, but the error is clearly identified and corrected. Using correction fluid, scribbling through the error, or using red ink are not appropriate methods as they may obscure the original information or make the correction difficult to read. Removing the page and starting over is also not necessary as long as the correction is clearly identified.

Question 10

What information is included when charting by the exception (CBE) method?

Accepted Answer

Charting by exception (CBE) focuses on documenting deviations from predefined norms, standards, or expectations. The nutritional care plan would be included in CBE documentation to highlight any deviations from the planned nutritional care, rather than routine measurements or assessments like height, weight, BMI, estimated energy requirements, dietary assessment data, or results of physical exams, which are typically documented comprehensively elsewhere.

Question 11

Identify the most important goal of documentation in the medical record.

Accepted Answer

The most important goal of documentation in the medical record is to be clear and concise. This ensures that the information is accurate, easily understandable, and accessible to other healthcare providers involved in the patient's care. Following ADA format, developing a new method of charting, using medical abbreviations or demonstrating knowledge of medicine and dietetics are all secondary goals to clear and concise documentation.

Question 12

Which of the following charting formats consists of a blending and reduction of the SOAP and IER formats?

Accepted Answer

The answer of Which of the following charting formats consists...

Question 13

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

Accepted Answer

CPT stands for Current Procedural Terminology, which is a standardized coding system used to document medical procedures and services. It is maintained by the American Medical Association and helps ensure accurate and consistent billing and insurance claims.

Question 14

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

Accepted Answer

The Joint Commission's official "Do Not Use" list includes the abbreviation IU (which stands for “International Unit”) because it can be mistaken for “IV” (intravenous) or “10” (the Roman numeral for ten). The other options – mg, mL, mEq, and kg – are still acceptable to use as long as they are written clearly and without ambiguity.

Question 15

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

Accepted Answer

The patient's medical chart keeps a record of what has been done for the patient, including medical treatments, medications, test results, and vital signs. It serves as a comprehensive history of the patient's healthcare that healthcare professionals can access when caring for the patient in the future.

Question 16

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

Accepted Answer

An electronic health record (EHR) is a digital version of a patient's paper chart. It includes information from all healthcare professionals involved in the patient's care and is designed to be accessible wherever the patient receives care. An electronic medical record (EMR) typically only includes information from one healthcare provider, while a personal health record (PHR) is controlled by the patient and may not include a complete record of their care. A medical chart and patient register refer to paper-based documentation of patient health information.

Question 17

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

Accepted Answer

The list of the patient's medications and supplements would fall under the assessment section of the ADIME format, which focuses on gathering and documenting the patient's current health status, medical history, medications, and other relevant information. This information is essential for developing a comprehensive nutrition care plan that takes into account the patient's medical history, potential medication-nutrient interactions, and other factors that may impact the patient's nutritional needs and dietary habits.

Question 18

Which of the following is a part of the problem-oriented medical record (POMR)?

Accepted Answer

Progress notes are a key part of the problem-oriented medical record (POMR) system, which emphasizes the identification and management of specific patient problems or issues. Research results, billing statements, reimbursement policies, and facility medical procedures are not specifically part of the POMR.

Question 19

Which action would be involved with bracketing biases when charting?

Accepted Answer

Bracketing biases involves imagining how an unbiased health professional would respond and remaining aware of potential biases that might influence the objectivity of the charting. A, B, D, and E have more to do with general principles of charting rather than specifically bracketing biases.

Question 20

The "E" in PES stands for:

Accepted Answer

The "E" in PES stands for "etiology," which is part of the PES statement used in nutrition and dietetics to identify the root cause of a nutrition problem.

Quiz 6: Nutrition Informatics and Documentation of the Nutrition Care Process