Exam 6: Documentation of the Nutrition Care Process

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

Which describes a section of the problem-oriented medical record (POMR)?​

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

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

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

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

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

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

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

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

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

A patient has developed a pressure ulcer from lying in bed. This information should be documented in which part of ADIME charting?​

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

Health professionals probably ought to write even more than they do because keeping personal notes in addition to required documentation of nutrition care provides greater opportunities for insights.

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

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

Which information is included in the charting by exception (CBE) method?​

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

Which would be considered an acceptable medical abbreviation?​

One of the most important goals of documentation in the medical record is:​