A violation of a patient's confidentiality may take the form of:
a. discussing a patient's status with the local pharmacist.
b. discussing a patient's status with his or her physician.
c. discussing a patient's status with his/her spouse in the patient's room.
d. discussing a patient's status with physical therapist who treats the patient.
Q. 2The law that assures patient confidentiality is called:
a. JCAHO.
b. ADIME.
c. HIPAA.
d. POMR.
Q. 3Which of the following is true about writing for the medical record?
a. You should set aside your biases.
b. Abbreviations are well interpreted by all reading your notes.
c. It is best to chart before a patient has a procedure.
d. You must use complete sentences.
Q. 4Which of the following would not appear in a CBE note?
a. a flowchart
b. a standardized nutritional care plan
c. an unexpected physiological response to an intervention
d. lab findings from day 5 that were all WNL
Q. 5One of the most important goals of documentation in a medical record is:
a. to be clear and concise.
b. to develop your own method of charting.
c. to follow the ADA format.
d. to use medical abbreviations.
Q. 6The PES statement is:
a. used to describe the patient's compliance to nutrition interventions.
b. a statement of the nutrition diagnosis.
c. an extension of the medical diagnosis.
d. developed by the interdisciplinary team.
Q. 7The form of documentation that is organized to reflect the nutrition care process is:
a. SOAP.
b. ADIME.
c. Focus notes.
d. PIE.
Q. 8Documentation of referral to a social worker would be included in which section of the SOAP note?
a. S
b. O
c. A
d. P
Q. 9Inferences about the medical data or your observations from the patient would be interpreted in which section of the SOAP note?
a. S
b. O
c. A
d. P
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