One quality improvement being made to charting is:
a. the RD documenting care in the progress notes.
b. electronic documentation.
c. restricting patient access to records.
d. changing the organization of the medical record to POMR.
Q. 2Audits, determining patient care, and legal proceedings are all uses for:
a. the medical record.
b. physician progress notes.
c. interdisciplinary team rounds.
d. DRGs.
Q. 3Specific standards that guide documentation in a medical record are devised by:
a. the dietitian.
b. the clinical nutrition manager.
c. accrediting agencies.
d. the physicians.
Q. 4Of all of the genres in which dietitians express themselves, which one would be most often viewed by an interdisciplinary team?
a. brochures
b. charting
c. handouts
d. memos
Q. 5Which of the following is not a step in the nutrition care process?
a. nutrition screening
b. nutrition diagnosis
c. nutrition monitoring and Evaluation
d. nutrition assessment
Q. 6You have an 80 yo M patient that has end-stage Alzheimer's disease and has recently been diagnosed with severe dysphagia. This patient is getting ready for discharge from the hospital. His height is 5' 9'' and he weighs 162 with no recent changes in weight. What is the most important parameter for the RD to follow up on with this patient on the second day?
a. refeeding syndrome
b. gastrointestinal tolerance
c. dehydration
d. tube dislodgement
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