Nutrition Therapy and Pathophysiology 3rd Edition by Marcia Nahikian – Test Bank

Nutrition Therapy and Pathophysiology 3rd Edition by Marcia Nahikian – Test Bank

Chapter 06 – Documentation of the Nutrition Care Process

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

a.

​diagnosis.

b.

​judgment.

c.

​analysis.

d.

​conclusion.

e.

​investigation.

ANSWER:

a

DIFFICULTY:

Bloom’s: Remember

REFERENCES:

Introduction

2. Which describes a function of the patient’s medical chart?​

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

ANSWER:

d

DIFFICULTY:

Bloom’s: Apply

REFERENCES:

Charting: Documentation of the Nutrition Care Process

3. 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

ANSWER:

b

DIFFICULTY:

Bloom’s: Remember

REFERENCES:

Charting: Documentation of the Nutrition Care Process

4. 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:​

a.

​electronic medical record (EMR).

b.

​medical chart.

c.

​electronic health record (EHR).

d.

​patient register.

e.

​personal health record (PHR).

ANSWER:

c

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

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

a.

​progress notes

b.

​research results

c.

​billing statements

d.

​reimbursement policies

e.

​facility medical procedures

ANSWER:

a

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

6. Which 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:

e

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

7. The “I” in ADIME charting stands for:​

a.

​ideal.

b.

​impaired.

c.

​identification.

d.

​intervention

e.

​interaction.

ANSWER:

d

DIFFICULTY:

Bloom’s: Remember

REFERENCES:

Charting: Documentation of the Nutrition Care Process

8. Which abbreviation is on the Joint Commission’s official “Do Not Use” list?​

a.

​mg

b.

​IU

c.

​mL

d.

​mEq

e.

​kg

ANSWER:

b

DIFFICULTY:

Bloom’s: Remember

REFERENCES:

Charting: Documentation of the Nutrition Care Process

9. 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.

​Assessment

b.

​Diagnosis

c.

​Monitoring

d.

​Evaluation

e.

​Inference

ANSWER:

a

DIFFICULTY:

Bloom’s: Apply

REFERENCES:

Charting: Documentation of the Nutrition Care Process

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

a.

​ADIME

b.

​IEP

c.

​PIE notes

d.

​ISFP

e.

​Focus notes

ANSWER:

e

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

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

a.

​the patient’s height, weight, and BMI

b.

​estimated energy requirements

c.

​the nutritional care plan

d.

​dietary assessment data

e.

​results of the physical exam

ANSWER:

c

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

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

a.

​just before the procedure

b.

​just after the procedure

c.

​the day after the procedure

d.

​only when there are significant results

e.

​before the patient is discharged

ANSWER:

b

DIFFICULTY:

Bloom’s: Apply

REFERENCES:

Charting: Documentation of the Nutrition Care Process

13. 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 professional would respond

d.

​Recording feelings and responses to the patient’s behavior

e.

​Documenting personal discussions by placing a bracket around the words

ANSWER:

c

DIFFICULTY:

Bloom’s: Apply

REFERENCES:

Charting: Documentation of the Nutrition Care Process

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

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

ANSWER:

b

DIFFICULTY:

Bloom’s: Apply

REFERENCES:

Charting: Documentation of the Nutrition Care Process

15. Which information would go under the “I” section of an IER note?​

a.

​laboratory data

b.

​record of intake and output

c.

​dietary assessment data

d.

​plans for follow-up

e.

​nutrition education

ANSWER:

e

DIFFICULTY:

Bloom’s: Apply

REFERENCES:

Charting: Documentation of the Nutrition Care Process

16. 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

ANSWER:

a

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

17. Which would be considered an acceptable medical abbreviation?​

a.

QD

b.

​U

c.

​cc

d.

​mmHg

e.

​IU

ANSWER:

d

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

18. A physician has ordered 6U of insulin for a patient. Which 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

ANSWER:

d

DIFFICULTY:

Bloom’s: Apply

REFERENCES:

Charting: Documentation of the Nutrition Care Process

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

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.

ANSWER:

a

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

20. 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.

ANSWER:

b

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

21. 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

ANSWER:

b

DIFFICULTY:

Bloom’s: Apply

REFERENCES:

Charting: Documentation of the Nutrition Care Process

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

a.

​Assessment

b.

​Diagnosis

c.

​Intervention

d.

​Monitoring

e.

​Evaluation

ANSWER:

a

DIFFICULTY:

Bloom’s: Apply

REFERENCES:

Charting: Documentation of the Nutrition Care Process

23. 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

ANSWER:

d

DIFFICULTY:

Bloom’s: Apply

REFERENCES:

Charting: Documentation of the Nutrition Care Process

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. Which 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

ANSWER:

c

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

25. 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?

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

ANSWER:

e

DIFFICULTY:

Bloom’s: Apply

REFERENCES:

Charting: Documentation of the Nutrition Care Process

26. 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

ANSWER:

d

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

27. Which constitutes 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

ANSWER:

a

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

28. 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.

ANSWER:

e

DIFFICULTY:

Bloom’s: Remember

REFERENCES:

Beyond Charting: An Overview of Writing in the Profession

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

a.

​spirit.

b.

​nature.

c.

​ethos.

d.

​temperament.

e.

​philosophy.

ANSWER:

c

DIFFICULTY:

Bloom’s: Remember

REFERENCES:

Beyond Charting: An Overview of Writing in the Profession

30. Which best describes writing processes?

a.

​A universal contextual framework

b.

​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.

​An ability to choose the appropriate words

ANSWER:

d

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Beyond Charting: An Overview of Writing in the Profession

31. Levels of discourse are generally described as:

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.

ANSWER:

b

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Beyond Charting: An Overview of Writing in the Profession

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

a.

​invention

b.

​editing

c.

​drafting

d.

​sentence generation

e.

​revision

ANSWER:

a

DIFFICULTY:

Bloom’s: Remember

REFERENCES:

Beyond Charting: An Overview of Writing in the Profession

33. Which best describes the process of pre-writing?​

a.

​recalibrating thinking

b.

​setting goals

c.

​planning the text

d.

​making minor corrections

e.

​eliminating unnecessary material

ANSWER:

c

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Beyond Charting: An Overview of Writing in the Profession

34. 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

ANSWER:

c

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Beyond Charting: An Overview of Writing in the Profession

35. The ethos is an important component of writing because:​

a.

​it allows the reader to understand the text more fully.

b.

​it establishes the nutrition professional as the expert.

c.

​it describes the focus of the writing.

d.

​it considers the education level of the audience.

e.

​it documents information for legal purposes.

ANSWER:

b

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Conclusion: Your Ethos—Establishing Experience

Case Study Multiple Choice

A healthcare 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 transition to new documentation is smooth.

36. 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

ANSWER:

a

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

PREFACE NAME:

healthcare

​

37. 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

ANSWER:

a

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

PREFACE NAME:

healthcare

38. 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.

​CBE

b.

​PIE notes

c.

​IER format

d.

​focus notes

e.

​IEP format

ANSWER:

c

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

PREFACE NAME:

healthcare

39. The “P” in PIE notes stands for:​

a.

​procedure.

b.

​plan.

c.

​policy.

d.

​problem

e.

​patient.

ANSWER:

d

DIFFICULTY:

Bloom’s: Remember

REFERENCES:

Charting: Documentation of the Nutrition Care Process

PREFACE NAME:

healthcare

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

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.

ANSWER:

c

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

PREFACE NAME:

healthcare

41. 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.​

a.

True

b.

False

ANSWER:

True

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Introduction

42. ​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.

a.

True

b.

False

ANSWER:

True

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

43. 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.​

a.

True

b.

False

ANSWER:

True

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

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

a.

True

b.

False

ANSWER:

False

DIFFICULTY:

Bloom’s: Remember

REFERENCES:

Charting: Documentation of the Nutrition Care Process

45. 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.

a.

True

b.

False

ANSWER:

False

DIFFICULTY:

Bloom’s: Understand

REFERENCES:

Charting: Documentation of the Nutrition Care Process

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

a.

True

b.

False

ANSWER:

True

DIFFICULTY:

Bloom’s: Remember

REFERENCES:

Charting: Documentation of the Nutrition Care Process