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NHM 365 > Module 1 - Nutrition Care Process (NCP) > Flashcards

Module 1 - Nutrition Care Process (NCP) Flashcards

1
Q

What is Step #1 in the NCP?

A
  • Obtain/collect important and relevant data
  • Analyze/interpret collected data
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2
Q

What is Step #2 in the NCP?

A
  • PES (problem, etiology and signs/symptoms)
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3
Q

In PES, P (problem) is what?

A

A nutrition diagnosis label

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4
Q

In PES, the 3 general domains of the P (problem) are:

A
  • Intake (NI)
  • Clinical (NC)
  • Behavioral/environmental (NB)
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5
Q

Intake (NI) is:

A

excessive or inadequate intake compared to requirements

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6
Q

Clinical (NC) is:

A

medical or physical conditions that are outside normal

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7
Q

Behavioral/environmental (NB) is:

A

knowledge, attitudes, beliefs, physical environment, access to food, food safety

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8
Q

In PES, E (etiology) is what?

A

the cause of the problem and contributing factors

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9
Q

Characteristics of etiology are:

A

-related factors that contribute to problem
- identifies cause of the problem
- helps determine whether nutrition intervention will improve problem
- linked to problem by words “related to”

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10
Q

T/F: Etiology may not always be clear.

A

T

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11
Q

What part of PES is this statement?

Excessive energy intake (NI-1.3) (problem) “related to” regular consumption of large portions at meals (etiology)…

A

E

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12
Q

What part of PES is this statement?

Swallowing difficulty (NC-1.1) (problem) related to recent CVA (etiology)…

A

E

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13
Q

What part of PES is this statement?

Unintended weight gain (NC-3.4) related to decrease in exercise following ankle surgery.

A

E

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14
Q
  • The focus of monitoring and evaluation
  • Defining characteristics

Are P, E, or S?

A

S (signs and symptoms)

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15
Q

What are the characteristics of signs and symptoms?

A
  • Evidence that a problem exists
  • Multiple examples make stronger statements
  • Linked to etiology by words “as evidenced by”
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16
Q

Evaluation and monitoring of effectiveness of intervention is done by reviewing what?

A

Signs and symptoms

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17
Q

Etiology usually __________ the intervention.

A

Guides

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18
Q

T/F: It’s ok to guess the etiology.

A

F

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19
Q

T/F: “Unknown etiology is acceptable terminology.

A

T

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20
Q

Which step of the NCP is this?

  • Determine intervention and prescription
  • Formulate goals and determine action
  • Implement action
A

NCP Step 3: Nutrition Intervention

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21
Q

Which step of the NCP is this?

  • Select or identify quality indicators
  • Monitor and evaluate resolution of diagnosis
A

NCP Step 4: Nutrition Monitoring and Evaluation

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22
Q

Define “evidence-based dietetics practice”

A

The use of systematically reviewed scientific evidence in making food and nutrition practice designs by integrating best available evidence with professional expertise and client values to improve outcomes.

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23
Q

Parts of a medical record include what?

A
  • Demographics
  • MD orders (incl. diet orders)
  • Hx and physical (H&P)
  • Graphic sheets (flow sheets)
  • Lab reports
  • Radiology reports
  • Medication records
  • Progress notes (MD, nursing, RDN, social work, therapists - PT, OT, SLP, etc.)
  • Consultation reports
  • Discharge summary
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24
Q

What is EHR (Electronic Health Record)?

A

An integration of all medical documentation into electronic format.

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25
Q

What are progress notes?

A
  • Daily updates entered into medical records
  • May be in SOAP, ADIME, narrative, or other formats
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26
Q

T/F: Progress notes are entered by al members of the health care team.

A

T

27
Q

T/F: Progress notes are not kept in chronological order.

A

F

28
Q

What is a medical record?

A

A legal document of written documentation of the NCP, including interventions and activities used to meet the nutritional objectives.

29
Q

HIPAA stands for what?

A

Health Insurance Portability and Accountability Act

30
Q

PHI stands for what?

A

Protected Health Information

31
Q

What is PHI?

A
  • Written documentation from medical records (including paper and electronic databases)
  • Spoken or voicemails info including voicemail messages
  • Photographic images
  • Audio and video recordings
32
Q

Wrongfully accessing or disclosing PHI: fines up to $____________ and up to ______yr/s in prison.

A

$50,000; 1 yr

33
Q

Obtaining PHI under false pretenses: fines up to $___________ and up to _____ yr/s in prison.

A

$100,00; 5 yrs

34
Q

Wrongfully using PHI for commercial activity: fines up to $_______________ and up to ___ yr/s in prison.

A

$250,000; 10 yrs

35
Q

T/F: HIPAA criminal and civil fines can be enforced against individuals as well as covered facilities.

A

T

36
Q

T/F: A HIPAA violation could be grounds for immediate dismissal from your internship!

A

T

37
Q

Nutrition Care Documentation is used for:

A
  1. Quality assurance
  2. Communication among the health care team
  3. Verifies care given
  4. Required for Joint Commission accreditation and state audits
38
Q

T/F: All entries for medical record documentation can be written in any ink color or typewritten.

A

F only black ink

39
Q

T/F: All entries for medical record documentation should include the date, time, and service.

A

T

40
Q

T/F: Abbreviations are okay to use in medical record documentation.

A

F

41
Q

The __________ _________________ has a list of forbidden hand-written abbreviations (the Do Not Use list) which have been associated with medical errors in the past.

A

Joint Commission

42
Q

T/F: Medical record documentation should be done in advance.

A

F - it should be done at the time of service or procedure is performed

43
Q

T/F: All entries for medical record documentation should be signed at the end and include credentials.

A

T

44
Q

T/F: When making corrections on medical record documentations, do not obliterate the original entry. Draw a single line through it, note “error” and correct it, listing the date and time of the correction, and your initials.

A

T

45
Q

ADIME documentation style

A
  • Assessment
  • Diagnosis
  • Intervention
  • Monitoring
  • Evaluation
46
Q

DAP documentation style

A
  • Diagnosis
  • Assessment
  • Plan
47
Q

PIE documentation style

A
  • Problem
  • Intervention
  • Evaluation
48
Q

IER documentation style

A
  • Intervention
  • Evaluation
  • Revision
49
Q

SAP documentation style

A
  • Subjective
  • Assess
  • Plan
50
Q

SOAPIER documentation style

A
  • Subjective
  • Objective
  • Analysis/assessment
  • Plan
  • Intervention
  • Evaluation
  • Revisions
51
Q

SOAP documentation style

A
  • Subjective
  • Objective
  • Assessment
  • Plan
52
Q

An assessment presents all data pertinent to ________ decision making.

A

clinical

53
Q
  • Food/Nutrition-Related History
  • Anthropometric Measurements
  • Biochemical Data, Medical Tests, and Procedures
  • Nutrition-Focused Physical Findings
  • Client History

Are all examples of what?

A

Assessments

54
Q

A nutrition diagnosis includes a _____ statement.

A

PES

55
Q

What is the Medical Dx of:

Excessive CHO intake (NI 5.8.2) related to evening visits to Coldstone Creamery as evidenced by diet hx and high hx blood glucose?

A

Diabetes

56
Q

What is the Medical Dx of:

Increased energy expenditure (NI 1.1) related to trauma from MVA as evidenced by results of indirect calorimetry?

A

Trauma and closed head injury

57
Q

What is the Medical Dx of:

Altered GI function (NC 1.4) related to Crohn’s disease as evidenced by steatorrhea and reports of abdominal pain with eating?

A

Inflammatory Bowel Disease (IBD)

58
Q

What is the Medical Dx of:

Excessive energy intake (NI 1.3) related to consumption of large portions at restaurants as evidenced by pt report of frequent fast food meals and BMI of 35.2 kg/m^2?

A

Obesity

59
Q

What is the Medical Dx of:

Disordered eating pattern (NB 1.5) related to history of anorexia nervosa and self-restrictive eating as evidenced by diet history and weight loss of 15 lbs in 3 mos?

A

Anorexia nervosa

60
Q

Intervention is what you recommend or plan to do to address the _________ __________.

A

Nutrition diagnoses

61
Q
  • Nutrition education (E)
  • Nutrition counseling (C)
  • Coordination of nutrition care (RC)

Are examples of what?

A

Intervention

62
Q

This type of data is info provided by the pat, family or other close person to the pt.

  • Reported wt loss or gain
  • Physical activity level
  • Work schedule
  • Nutritional hx (usual eating pattern, cooking, eating out, etc.)
  • Socioeconomic info, cultural info

s____________

A

subjective

63
Q

This type of data is factual, reproducible observations.

  • Dx
  • Ht, wt, age
  • Lab data
  • Clinical data (abd distension, diarrhea, etc.)
  • Diet order
  • Pertinent meds
  • Estimation of nutrition needs

o_____________

A

objective

NHM 365 (23 decks)

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