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

When charting by the exception method, a(n) _______________ indicates an abnormal finding on an assessment or an abnormal response to an intervention.

_______________ involves whatever it is that the writer does before actually writing.

List each component of the following acronyms: SOAP, ADIME, IER.

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 information contained in the "O" portion of the SOAP note would now be written in which part of the ADIME note?

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

When charting, remember that medical charts are _______________ documents as well as medical documents.

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 information written in the "S" portion of the SOAP format would now be written in which portion of the ADIME note?

Which factor is essential to keep in mind while documenting in a patient's chart?

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 information from the SOAP note is consolidated into three sections: writing the patient's data, the nutritionist's interventions, and the patient's response to the interventions. This process most likely reflects which type of charting?

The ethos is an important component of writing because it:

In order for a health care provider to receive payment, the patient's medical record at discharge must contain documentation of the ______________.

Discuss each of the following steps in the writing process: prewriting, drafting, revision, editing.

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 overall movement in charting over the last decade has been toward:

The _______________ section of ADIME charting is where the actual PES statements are listed and prioritized.

A dietitian must record a patient's nutrition information in his chart, and she is waiting for the nurse to finish her notes. Which guideline must the dietitian consider when she gets the chart and starts her own documentation?

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

Which of the following best describes the process of prewriting?

Which situation would be considered a violation of a patient's right to confidentiality?

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

Which genre written by a clinical dietitian would most likely be viewed by other members of the interdisciplinary team?