Question 1

Which charting format consists of a combination and reduction of the SOAP and IER formats?​

Accepted Answer

A)  ​ADIME 
B)  ​IEP 
C)  ​PIE notes 
D)  ​ISFP 
E)  ​Focus notes 
A)  ​ADIME 
B)  ​IEP 
C)  ​PIE notes 
D)  ​ISFP 
E)  ​Focus notes E

Question 2

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

Accepted Answer

A)  ​SOAP note. 
B)  ​PES. 
C)  ​focus notes. 
D)  ​nutrition diagnosis. 
E)  ​progress notes. 
A)  ​SOAP note. 
B)  ​PES. 
C)  ​focus notes. 
D)  ​nutrition diagnosis. 
E)  ​progress notes. B

Question 3

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.

Accepted Answer

A) True 
 B)False  True

Question 4

When describing the steps of the writing process, which would be considered the first step?​

Accepted Answer

A)  ​invention 
B)  ​editing 
C)  ​drafting 
D)  ​sentence generation 
E)  ​revision 
A)  ​invention 
B)  ​editing 
C)  ​drafting 
D)  ​sentence generation 
E)  ​revision

Question 5

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

Accepted Answer

A)  ​diagnosis. 
B)  ​judgment. 
C)  ​analysis. 
D)  ​conclusion. 
E)  ​investigation. 
A)  ​diagnosis. 
B)  ​judgment. 
C)  ​analysis. 
D)  ​conclusion. 
E)  ​investigation.

Question 6

The Joint Commission recommends that certain abbreviations not be used because they are more likely to contribute to _______________.

Accepted Answer

​errors, p

Question 7

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?​

Accepted Answer

A)  ​CBE 
B)  ​PIE notes 
C)  ​IER format 
D)  ​focus notes 
E)  ​IEP format 
A)  ​CBE 
B)  ​PIE notes 
C)  ​IER format 
D)  ​focus notes 
E)  ​IEP format

Question 8

The rhetorical norms of writing are the different levels of writing on which one can focus attention.

Accepted Answer

A) True 
 B)False

Question 9

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

Accepted Answer

A)  ​6 Un 
B)  ​Six U 
C)  ​Six units 
D)  ​6 units 
E)  ​6 ut 
A)  ​6 Un 
B)  ​Six U 
C)  ​Six units 
D)  ​6 units 
E)  ​6 ut

Question 10

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

Accepted Answer

The answer of The _______________ section of ADIME charting is...

Question 11

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

Accepted Answer

A)  ​spirit. 
B)  ​nature. 
C)  ​ethos. 
D)  ​temperament. 
E)  ​philosophy. 
A)  ​spirit. 
B)  ​nature. 
C)  ​ethos. 
D)  ​temperament. 
E)  ​philosophy.

Question 12

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

Accepted Answer

The answer of All writing involves subject matter, a purpose,...

Question 13

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

Accepted Answer

A)  ​mg 
B)  ​IU 
C)  ​mL 
D)  ​mEq 
E)  ​kg 
A)  ​mg 
B)  ​IU 
C)  ​mL 
D)  ​mEq 
E)  ​kg

Question 14

A nutrition practitioner has just made an error while writing in a chart. Which is the best method of correcting the situation?

Accepted Answer

A)  ​Remove the page from the chart and start over 
B)  ​Draw a line through the error and initial it 
C)  ​Use correction fluid and write over it 
D)  ​Scribble through the error and initial it 
E)  ​Use red ink to write "error" and initial it 
A)  ​Remove the page from the chart and start over 
B)  ​Draw a line through the error and initial it 
C)  ​Use correction fluid and write over it 
D)  ​Scribble through the error and initial it 
E)  ​Use red ink to write "error" and initial it

Question 15

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

Accepted Answer

The answer of The levels of _______________ include the different...

Question 16

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

Accepted Answer

A)  ​electronic medical record (EMR). 
B)  ​medical chart. 
C)  ​electronic health record (EHR). 
D)  ​patient register. 
E)  ​personal health record (PHR). 
A)  ​electronic medical record (EMR). 
B)  ​medical chart. 
C)  ​electronic health record (EHR). 
D)  ​patient register. 
E)  ​personal health record (PHR).

Question 17

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

Accepted Answer

A)  ​Reviewing the patient's care plan with his physician 
B)  ​Discussing the patient's condition with the physical therapist involved in the case 
C)  ​Talking about medications while the patient's spouse is in the room 
D)  ​Discussing the patient's status with a local pharmacist 
E)  ​Explaining the goals of treatment for the patient with his nurse 
A)  ​Reviewing the patient's care plan with his physician 
B)  ​Discussing the patient's condition with the physical therapist involved in the case 
C)  ​Talking about medications while the patient's spouse is in the room 
D)  ​Discussing the patient's status with a local pharmacist 
E)  ​Explaining the goals of treatment for the patient with his nurse

Question 18

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

Accepted Answer

A)  ​brochures 
B)  ​memos 
C)  ​charts 
D)  ​handouts 
E)  ​pamphlets 
A)  ​brochures 
B)  ​memos 
C)  ​charts 
D)  ​handouts 
E)  ​pamphlets

Question 19

Levels of discourse are generally described as:

Accepted Answer

A)  ​the reasons for writing the text. 
B)  ​norms, ideas, organization, and grammar. 
C)  ​the readers to whom the writing is directed. 
D)  ​styles, lettering, and fonts. 
E)  ​the characters and settings the writing is about. 
A)  ​the reasons for writing the text. 
B)  ​norms, ideas, organization, and grammar. 
C)  ​the readers to whom the writing is directed. 
D)  ​styles, lettering, and fonts. 
E)  ​the characters and settings the writing is about.

Question 20

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

Accepted Answer

A)  ​Include less information, rather than too much 
B)  ​Only record assumptions at the end of documentation 
C)  ​Add a signature only with written documentation, not electronic 
D)  ​Avoid abbreviations unless it is clear that anyone can understand them 
E)  ​Only chart what others see as significant 
A)  ​Include less information, rather than too much 
B)  ​Only record assumptions at the end of documentation 
C)  ​Add a signature only with written documentation, not electronic 
D)  ​Avoid abbreviations unless it is clear that anyone can understand them 
E)  ​Only chart what others see as significant

Exam 6: Documentation of the Nutrition Care Process

Which charting format consists of a combination and reduction of the SOAP and IER formats?​

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

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.

When describing the steps of the writing process, which would be considered the first step?​

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

The Joint Commission recommends that certain abbreviations not be used because they are more likely to contribute to _______________.

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 rhetorical norms of writing are the different levels of writing on which one can focus attention.

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

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

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

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

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

A nutrition practitioner has just made an error while writing in a chart. Which is the best method of correcting the situation?

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

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

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

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

Levels of discourse are generally described as:

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

Role of the Dietitian in the Health Care System

The Nutrition Care Process

Nutrition Assessment - Foundation of the Nutrition Care Process

Nutrition Intervention and Nutrition Monitoring and Evaluation

Enteral and Parental Nutrition Support

Fluid and Electrolyte Balance

Acid Base Balance

Cellular and Physiological Response to Injury - the Role of the Immune System

Nutritional Genomics

Pharmacology

Diseases and Disorders of Energy Imbalance

Diseases of the Cardiovascular System

Diseases of the Upper Gastrointestinal Tract

Diseases of the Lower Gastrointenstinal Tract

Diseases of the Liver - Gallbladder - and Exocrine Pancreas

Diseases of the Endocrine System

Diseases of the Renal System

Diseases of the Hematological System

Diseases and Disorders of the Neurological System

Diseases of the Respiratory System

Metabolic Stress and the Critically Ill

Neoplastic Disease

HIV and Aids

Diseases of the Musculoskeletal System

Metabolic Disorders

Filters

Which charting format consists of a combination and reduction of the SOAP and IER formats?

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

When describing the steps of the writing process, which would be considered the first step?

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

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?

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

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

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

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

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