Question 1

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

Accepted Answer

The answer of A set of readers to whom the...

Question 2

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

Accepted Answer

​Charting by exception (CBE) is an abbre...

Question 3

Which best describes writing processes?

Accepted Answer

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

Question 4

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

Accepted Answer

The answer of When charting, remember that medical charts are...

Question 5

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?​

Accepted Answer

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

Question 6

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

Accepted Answer

A) True 
 B)False

Question 7

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

Accepted Answer

​Three important areas of writing need t...

Question 8

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?

Accepted Answer

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 9

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 _______________​

Accepted Answer

​electroni...

Question 10

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

Accepted Answer

​Health professionals should consider ke...

Question 11

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

Accepted Answer

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

Question 12

The "I" in ADIME charting stands for:​

Accepted Answer

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

Question 13

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

Accepted Answer

​Examples of guidelines for charting inc...

Question 14

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?

Accepted Answer

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

Question 15

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."​

Accepted Answer

​electroni...

Question 16

The ethos is an important component of writing because:​

Accepted Answer

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.

Question 17

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

Accepted Answer

A)   ​laboratory data
B)   ​record of intake and output
C)   ​dietary assessment data
D)   ​plans for follow-up
E)   ​nutrition education

Question 18

Which best describes the process of pre-writing?​

Accepted Answer

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

Question 19

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

Accepted Answer

​The federal U.S. law that assures patie...

Question 20

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

Accepted Answer

The answer of When referring to a patient while charting,...

Exam 6: Documentation of the Nutrition Care Process

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 _______________​

Correct Answerverified​electroni...View AnswerShow Answer

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?​

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

Which best describes writing processes?

Correct AnswerverifiedShow Answer

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

Correct Answerverified​Health professionals should consider ke...View AnswerShow Answer

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

Correct Answerverified​Examples of guidelines for charting inc...View AnswerShow Answer

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?

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

The ethos is an important component of writing because:​

Correct AnswerverifiedShow Answer

Which best describes the process of pre-writing?​

Correct AnswerverifiedShow Answer

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

Correct Answerverified​Three important areas of writing need t...View AnswerShow Answer

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

Correct AnswerverifiedShow Answer

The "I" in ADIME charting stands for:​

Correct AnswerverifiedShow Answer

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

Correct Answerverified​The federal U.S. law that assures patie...View AnswerShow Answer

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."​

Correct Answerverified​electroni...View AnswerShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct Answerverified​Charting by exception (CBE) is an abbre...View AnswerShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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 _______________

Correct Answer
verified
electroni...
View Answer

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?

Correct Answer
verified

Correct Answer
verified

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

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified
Health professionals should consider ke...
View Answer

Correct Answer
verified
Examples of guidelines for charting inc...
View Answer

Correct Answer
verified

Correct Answer
verified

The ethos is an important component of writing because:

Correct Answer
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Which best describes the process of pre-writing?

Correct Answer
verified

Correct Answer
verified
Three important areas of writing need t...
View Answer

Correct Answer
verified

The "I" in ADIME charting stands for:

Correct Answer
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Correct Answer
verified
The federal U.S. law that assures patie...
View Answer

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."

Correct Answer
verified
electroni...
View Answer

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

Correct Answer
verified

Correct Answer
verified
Charting by exception (CBE) is an abbre...
View Answer

Correct Answer
verified

Correct Answer
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