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

The Academy of Nutrition and Dietetics has promoted the use of the _______________ format because it mirrors the steps of the nutrition care process.

Steps to ensure accuracy of the medical record include the use of standard language and medical abbreviations.

Which of the following statements is true of the levels of discourse?

Differences in the writing of different communities-different disciplines, different workplaces-coalesce into what are referred to as _______________.

List three examples of guidelines for charting that are stated in the text.

The personality or voice that comes through the text and characterizes the writer for the reader is known as:

In IER notes, _______________ refers to the assessment part of SOAP, the diagnosis and evaluation based on the data gathered.

Which of the following best describes writing processes?

The "I" in ADIME charting stands for:

A dietitian is documenting a list of the patient's medications and supplements using the ADIME format. Which section of the charting format would this information fall under?

The data in the EMR is the legal record of what happened to the patient during his or her encounter with the care delivery organization and is owned by the patient.

A record of an individual's care that provides health information from all clinicians that provide care for that individual and is designed to follow the patient wherever they receive health care is known as the _______________.

Each state's licensing agency, as well as the Joint Commission, requires that all health care facilities monitor, evaluate, and seek ways to improve the quality of care for their patients.

A nutrition practitioner takes an X-ray of a patient's right leg that is swollen. Which of the following sections of the SOAP note will have this information?

The _______________ is designed to collect only de-identified nutrition diagnoses and follow-up data.

Discuss the purpose and give an example of charting by exception in the patient's medical record.

_______________ can also include sensory information noted by the medical staff member such as smell or the visual recording of patient's skin coloration.

The nutrition practitioner made an error while writing in a chart. What is the best method to correct the error?

The driving forces that impact medical record keeping include accrediting agencies for health care facilities, continuous quality improvement programs, and insurance reimbursement for medical care.

Name the elements involved with every rhetorical norm.