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

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

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."

The "E" in PES stands for:

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

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

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

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

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

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

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

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

The actual process of writing is usually always linear.

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

Subject matter refers to the personality or voice that comes through the text and characterizes the writer for the reader.

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

Which action would be involved with bracketing biases when charting?

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

Which of the following is the first step in the writing process?

A record of an individual's health care that includes information from all clinicians who provide care and that is set up, accessed, and managed by that individual patient is known as the _______________.

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