Exam 6: Documentation of the Nutrition Care Process

Case Study 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?

The law that assures patient confidentiality is called:

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

The PES statement is:

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

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

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

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

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

Case Study 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?

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

Case Study 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?

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

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

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

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

Case Study 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?

When writing, the ethos is an important component because:

Case Study 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?