Question 1

Clear, concise wording in the medical record, using terminology consistent with the _______________, will facilitate reimbursement for services.

Accepted Answer

​prospecti

Question 2

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

Accepted Answer

​the Joint

Question 3

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

Accepted Answer

A)  ​A 
B)  ​D 
C)  ​I 
D)  ​M 
E)  ​E 
A)  ​A 
B)  ​D 
C)  ​I 
D)  ​M 
E)  ​E

Question 4

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

Accepted Answer

A)  ​increasing the size of the medical record. 
B)  ​changing charting from SOAP format to ADIME. 
C)  ​decreasing the size of the medical record. 
D)  ​requiring workers to document more information. 
E)  ​eliminating the need for the medical record. 
A)  ​increasing the size of the medical record. 
B)  ​changing charting from SOAP format to ADIME. 
C)  ​decreasing the size of the medical record. 
D)  ​requiring workers to document more information. 
E)  ​eliminating the need for the medical record.

Question 5

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

Accepted Answer

The answer of When using the charting by exception method,...

Question 6

The "P" in PIE notes stands for:​

Accepted Answer

A)  ​procedure. 
B)  ​plan. 
C)  ​policy. 
D)  ​problem 
E)  ​patient. 
A)  ​procedure. 
B)  ​plan. 
C)  ​policy. 
D)  ​problem 
E)  ​patient.

Question 7

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

Accepted Answer

A)  ​Communicating information between medical professionals and the public 
B)  ​Evaluating medical care for the client's family 
C)  ​Upholding the Joint Commission's standards 
D)  ​Keeping a record of what has been done for the patient 
E)  ​Supporting the need for funding the non-profit facility 
A)  ​Communicating information between medical professionals and the public 
B)  ​Evaluating medical care for the client's family 
C)  ​Upholding the Joint Commission's standards 
D)  ​Keeping a record of what has been done for the patient 
E)  ​Supporting the need for funding the non-profit facility

Question 8

The actual process of writing is usually always linear.

Accepted Answer

A) True 
 B)False

Question 9

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

Accepted Answer

A)  ​A 
B)  ​D 
C)  ​I 
D)  ​M 
E)  ​E 
A)  ​A 
B)  ​D 
C)  ​I 
D)  ​M 
E)  ​E

Question 10

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

Accepted Answer

​Prewritin

Question 11

The label "SOAP" refers to the four sections of each entry in the medical chart: subjective data, _______________, assessment, and plan.

Accepted Answer

The answer of The label "SOAP" refers to the four...

Question 12

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.

Accepted Answer

A) True 
 B)False

Question 13

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

Accepted Answer

A) True 
 B)False

Question 14

The federal U.S. law that assures patients of the confidentiality of their medical information is the Health Insurance Portability and _______________ Act of 1996, or HIPAA.

Accepted Answer

The answer of The federal U.S. law that assures patients...

Question 15

Which action would be involved with bracketing biases when charting?​

Accepted Answer

A)  ​Getting rid of personal preferences and values 
B)  ​Describing information that is subjective to self 
C)  ​Imagining how an unbiased professional would respond 
D)  ​Recording feelings and responses to the patient's behavior 
E)  ​Documenting personal discussions by placing a bracket around the words 
A)  ​Getting rid of personal preferences and values 
B)  ​Describing information that is subjective to self 
C)  ​Imagining how an unbiased professional would respond 
D)  ​Recording feelings and responses to the patient's behavior 
E)  ​Documenting personal discussions by placing a bracket around the words

Question 16

Which type of information would be documented under the "S" portion of the SOAP format?​

Accepted Answer

A)  ​the patient's age 
B)  ​medical diagnosis 
C)  ​nutrition therapy recommendations 
D)  ​the patient's vital signs 
E)  ​psychosocial factors affecting care 
A)  ​the patient's age 
B)  ​medical diagnosis 
C)  ​nutrition therapy recommendations 
D)  ​the patient's vital signs 
E)  ​psychosocial factors affecting care

Question 17

Which constitutes a goal of the Health Insurance Portability and Accountability Act (HIPAA)?​

Accepted Answer

A)  ​Prevent the inappropriate use of protected health information 
B)  ​Prevent communication between financial institutions related to patient billing 
C)  ​Ensure that insurance companies are reimbursing appropriate amounts 
D)  ​Guarantee the safety of the patient's chart between admission and discharge 
E)  ​Ensure that the patient's chart is correctly transcribed into an electronic health record 
A)  ​Prevent the inappropriate use of protected health information 
B)  ​Prevent communication between financial institutions related to patient billing 
C)  ​Ensure that insurance companies are reimbursing appropriate amounts 
D)  ​Guarantee the safety of the patient's chart between admission and discharge 
E)  ​Ensure that the patient's chart is correctly transcribed into an electronic health record

Question 18

After interviewing a patient, the dietitian describes why he is at nutritional risk. This information should be recorded in which part of ADIME charting?​

Accepted Answer

A)  ​Assessment 
B)  ​Diagnosis 
C)  ​Intervention 
D)  ​Monitoring 
E)  ​Evaluation 
A)  ​Assessment 
B)  ​Diagnosis 
C)  ​Intervention 
D)  ​Monitoring 
E)  ​Evaluation

Question 19

Name the elements involved with every rhetorical norm.

Accepted Answer

​Subject matter: what the text is about

Question 20

The data portion of problem-oriented medical record is a list of expected outcomes and plans for further data collection.

Accepted Answer

A) True 
 B)False

Exam 6: Documentation of the Nutrition Care Process

Clear, concise wording in the medical record, using terminology consistent with the _______________, will facilitate reimbursement for services.

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

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

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

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

The "P" in PIE notes stands for:​

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

The actual process of writing is usually always linear.

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

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

The label "SOAP" refers to the four sections of each entry in the medical chart: subjective data, _______________, assessment, and plan.

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.

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

The federal U.S. law that assures patients of the confidentiality of their medical information is the Health Insurance Portability and _______________ Act of 1996, or HIPAA.

Which action would be involved with bracketing biases when charting?​

Which type of information would be documented under the "S" portion of the SOAP format?​

Which constitutes a goal of the Health Insurance Portability and Accountability Act (HIPAA)?​

After interviewing a patient, the dietitian describes why he is at nutritional risk. This information should be recorded in which part of ADIME charting?​

Name the elements involved with every rhetorical norm.

The data portion of problem-oriented medical record is a list of expected outcomes and plans for further data collection.

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

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

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

The "P" in PIE notes stands for:

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

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

Which action would be involved with bracketing biases when charting?

Which type of information would be documented under the "S" portion of the SOAP format?

Which constitutes a goal of the Health Insurance Portability and Accountability Act (HIPAA)?

After interviewing a patient, the dietitian describes why he is at nutritional risk. This information should be recorded in which part of ADIME charting?