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

Question 1

When should the nutrition practitioner begin charting information about a procedure performed on a patient?

A) just before the procedure
B) just after the procedure
C) the day after the procedure
D) at the time of admission
E) before the patient is discharged

Answer 1

B

Question 2

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?

A) analysis
B) assessment
C) subjective data
D) objective data
E) plan

Answer 2

D

Question 3

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

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

Answer 3

E

Question 4

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

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

Question 5

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

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

Question 6

The "I" in ADIME charting stands for:

A) ideal
B) impaired
C) identification
D) intervention
E) interaction

Question 7

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

A) subjective
B) objective
C) assessment
D) analysis
E) plan

Question 8

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

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

Question 9

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

A) Remove the page from the chart and start over.
B) Draw a horizontal line, write "error" above it, 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 10

What information is included when charting by the exception (CBE) method?

A) patient's height, weight, and BMI
B) estimated energy requirements
C) nutritional care plan
D) dietary assessment data
E) results of the physical exam

Question 11

Identify the most important goal of documentation in the medical record.

A) to be clear and concise
B) to follow ADA format
C) to develop a new method of charting
D) to use medical abbreviations
E) to demonstrate knowledge of medicine and dietetics

Question 12

Which of the following charting formats consists of a blending and reduction of the SOAP and IER formats?

A) ADIME
B) IEP
C) PIE notes
D) PES
E) focus notes

Question 13

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

A) Computerized Policies and Training
B) Current Procedural Terminology
C) Calculated Programs and Technology
D) Consistent Prospective Testing
E) Copied Preferences and Testimonies

Question 14

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

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

Question 15

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

A) communicating information between medical professionals and the public
B) evaluating medical care for the patient'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 nonprofit facility

Question 16

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

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

Question 17

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?

A) assessment
B) diagnosis
C) monitoring
D) evaluation
E) inference

Question 18

Which of the following is a part of the problem-oriented medical record (POMR)?

A) progress notes
B) research results
C) billing statements
D) reimbursement policies
E) facility medical procedures

Question 19

Which action would be involved with bracketing biases when charting?

A) getting rid of personal preferences and values
B) describing information that is subjective to self
C) imagining how an unbiased health 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 20

The "E" in PES stands for:

A) education
B) evaluation
C) editing
D) electronic
E) etiology

Question 21

A physician prescribed 15 ug of a vitamin D supplement to a patient, which resulted in an overdose. There was a potential problem with the units used. What should have been the correct quantity instead?

A) 15 mcg
B) 15 cc
C) 15 kg
D) 15 L
E) 15 unit

Question 22

Which of the following best describes the process of prewriting?

A) recalibrating thinking
B) setting goals
C) planning the text
D) making minor corrections
E) making minor corrections

Question 23

A health care facility has recently adopted a new method of documenting in the medical record. The dietitian was trained using the SOAP method, but now needs to transition to understanding different methods of charting to ensure that the transition to new documentation is smooth.
The information contained in the "O" portion of the SOAP note would now be written in which part of the ADIME note?

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

Question 24

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. What type of documentation format is the dietitian most likely using?

A) SOAP format
B) PIE notes
C) charting by exception
D) focus notes
E) ADIME format

Question 25

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

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

Question 26

Which of the following is the first step in the writing process?

A) invention
B) editing
C) drafting
D) proofing
E) revision

Question 27

A health care facility has recently adopted a new method of documenting in the medical record. The dietitian was trained using the SOAP method, but now needs to transition to understanding different methods of charting to ensure that the transition to new documentation is smooth .
The information written in the "S" portion of the SOAP format would now be written in which portion of the ADIME note?

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

Question 28

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

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 29

A health care facility has recently adopted a new method of documenting in the medical record. The dietitian was trained using the SOAP method, but now needs to transition to understanding different methods of charting to ensure that the transition to new documentation is smooth.
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) PES notes
B) PIE notes
C) IER notes
D) focus notes
E) IEP notes

Question 30

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

A) assessment
B) diagnosis
C) intervention
D) monitoring
E) evaluation

Question 31

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

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.

Question 32

Which of the following best describes writing processes?

A) a universal contextual framework
B) the different levels on which to focus attention
C) the organization of different sections of written work
D) the cognitive processes and stages of writing
E) the ability to choose the appropriate words

Question 33

The ethos is an important component of writing because it:

A) allows the reader to understand the text more fully
B) establishes the nutrition professional as the expert
C) describes the focus of the writing
D) considers the education level of the audience
E) documents information for legal purposes

Question 34

A health care facility has recently adopted a new method of documenting in the medical record. The dietitian was trained using the SOAP method, but now needs to transition to understanding different methods of charting to ensure that the transition to new documentation is smooth.
The overall movement in charting over the last decade has been toward:

A) increasing the size of the medical record
B) changing charting from the 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 35

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

A) They are a set of audience to whom the text is directed.
B) They consists of rhetorical norms, ideas, organization, and grammar.
C) They are the linear process for writing the text for audience.
D) They consist of styles, formatting, lettering, and fonts.
E) They provide the workplace without a context.

Question 36

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

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

Question 37

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

A) Review what the nurse wrote, and write the same information in her own words.
B) Leave a small amount of white space after the nurse's writing to add information later.
C) Ask the nurse to document the nutrition information as well.
D) Write a signature after the nursing information and the nutrition information.
E) Write clearly so that the nurse or anyone else reading the chart can understand the information.

Question 38

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

A) the language
B) the publication
C) the cognitive response
D) the objective information
E) the audience

Question 39

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

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 40

A health care facility has recently adopted a new method of documenting in the medical record. The dietitian was trained using the SOAP method, but now needs to transition to understanding different methods of charting to ensure that the transition to new documentation is smooth.
The "P" in PIE notes stands for:

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

Question 41

The rhetorical norms of writing refer to the universal contextual framework within which all communication exists.

Question 42

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

Question 43

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.

Question 44

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

Question 45

The actual process of writing is usually always linear.

Question 46

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.

Question 47

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

Question 48

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

Question 49

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

Question 50

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."

Question 51

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

Question 52

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.

Question 53

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

Question 54

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

Question 55

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

Question 56

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 _______________.

Question 57

A record of an individual's health care that includes information from all clinicians who provide care and that is set up, accessed, and managed by that individual patient is known as the _______________.

Question 58

Subject matter refers to the personality or voice that comes through the text and characterizes the writer for the reader.

Question 59

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

Question 60

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

Question 61

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

Question 62

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

Question 63

In order for a health care provider to receive payment, the patient's medical record at discharge must contain documentation of the ______________.

Question 64

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

Question 65

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

Question 66

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

Question 67

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

Question 68

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

Question 69

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

Question 70

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

Question 71

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

Question 72

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

Question 73

Name the elements involved with every rhetorical norm.

Question 74

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

Question 75

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

Question 76

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

Question 77

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.

Question 78

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

Question 79

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

Question 80

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