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

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

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

A physician prescribed 15 ug of a vitamin D supplement to a patient, which resulted in an overdose. There was a potential problem with the units used. What should have been the correct quantity instead?

The rhetorical norms of writing refer to the universal contextual framework within which all communication exists.

Which of the following is a goal of the Health Insurance Portability and Accountability Act (HIPAA)?

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.

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

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

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

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

A health care facility has recently adopted a new method of documenting in the medical record. The dietitian was trained using the SOAP method, but now needs to transition to understanding different methods of charting to ensure that the transition to new documentation is smooth. The "P" in PIE notes stands for:

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

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

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. What type of documentation format is the dietitian most likely using?

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

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

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

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

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:

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