Exam 6: Documentation of the Nutrition Care Process

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

A set of readers to whom the text is directed is known as the _______________.

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."​

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

When charting about a procedure performed on a patient, when should the nutrition practitioner chart the information?​

The "I" in ADIME charting stands for:​

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 _______________​

The ethos is an important component of writing because:​

Describe the parameters of the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

When referring to a patient while charting, use the term "patient" or "_______________," and not his or her name.

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

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

Which best describes writing processes?

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

Which best describes the process of pre-writing?​

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

Which information would go under the "I" section of an IER note?​

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

A dietitian is documenting information in a patient's chart. She writes an asterisk and then explains the information further in the comments section of the chart. Which type of documentation format is the dietitian most likely using?

Clients frequently request copies of their medical records, but they do not have the right to read those records.