and CORRECT Answers
Which section of your ADIME note will describe the parameters that you will be looking for in
your follow-up to see if your nutrition diagnosis is resolved? - CORRECT ANSWER -
M/E
A statement regarding the patient's nutritional status at this time would be recorded in which
section of the
SOAP note? - CORRECT ANSWER -A
The form of documentation that is organized to reflect the nutrition care process is: - CORRECT
ANSWER - ADIME
Your patient has just had labs drawn and there is an abnormal value. You would record this in
which section of the SOAP note? - CORRECT ANSWER -O
One quality improvement being made to charting is - CORRECT ANSWER - Electronic
documentation
Medical Record
1. Used to a___ & m____ the health care provided by an institution or a specific group of health
care providers
2. Always be c____ & c____
3. Always set aside your b____, preferably in brackets - CORRECT ANSWER - audit,
monitor
clear, concise
biases
When developing your PES statement, the signs and symptoms will likely come from which part
of your
,ADIME note? - CORRECT ANSWER -A
Data such as patient reports of nausea or vomiting would be recorded in which section of the
SOAP note? - CORRECT ANSWER -S
Which of the following is not a step in the nutrition care process? - CORRECT
ANSWER - Nutrition screening
Long-term care facilities that are receiving patients from the hospital would be most interested in
which portion of the medical record? - CORRECT ANSWER - The discharge summary
Documentation of referral to a social worker would be included in which section of the SOAP
note? - CORRECT ANSWER -P
Of all of the different styles of charting, which one is the most well known? - CORRECT
ANSWER - SOAP
Medical nutrition therapy strategies would be listed in which section of the SOAP note? -
CORRECT ANSWER -P
The law that assures patient confidentiality is called - CORRECT ANSWER - HIPPA
A violation of a patient's confidentiality may take the form of - CORRECT ANSWER -
Discussing a patient's status with the local pharmacist
Of all of the genres in which dietitians express themselves, which one would be most often
viewed by an interdisciplinary team (multiple health care professionals)? - CORRECT
ANSWER - Charting
Which of the following is not part of the POMR medical record? - CORRECT ANSWER -
Interdisciplinary treatment plan
, Inferences about the medical data or your observations from the patient would be interpreted in
which section of the SOAP note? - CORRECT ANSWER -A
A statement regarding the patient's nutritional status at this time would be recorded in which
section of the SOAP note? - CORRECT ANSWER -A
The PES statement is - CORRECT ANSWER - A statement of the nutrition diagnosis that
describes the specific nutrition problem the RD is responsible for treating & working toward
resolving the causes (etiology) of the prob. & evidence (signs/symptoms) that it exists.
Specific standards that guide documentation in a medical record are devised by - CORRECT
ANSWER - Accrediting agencies
Intervention strategies should be based on which of the following? - CORRECT
ANSWER - nutrition diagnoses and their etiology
Progress of Oral Feeding
1. N____
2. I___ chips
3. Sips of w____
4. C____ diet
5. F___ diet
6. S___ diet
7. General or adequate n___ diet - CORRECT ANSWER - 1. NPO (nothing by mouth)
2. ice
3. water
4. clear liquid
5. full liquid
6. soft/light