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. -Which of the following would be new to the RD who is transitioning to the ADIME format?

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

Which of the following is an acceptable medical abbreviation?

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

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

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

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

One quality improvement being made to charting is:

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

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

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

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