Module 1 - Nutrition Care Process (NCP) Flashcards
What is Step #1 in the NCP?
- Obtain/collect important and relevant data
- Analyze/interpret collected data
What is Step #2 in the NCP?
- PES (problem, etiology and signs/symptoms)
In PES, P (problem) is what?
A nutrition diagnosis label
In PES, the 3 general domains of the P (problem) are:
- Intake (NI)
- Clinical (NC)
- Behavioral/environmental (NB)
Intake (NI) is:
excessive or inadequate intake compared to requirements
Clinical (NC) is:
medical or physical conditions that are outside normal
Behavioral/environmental (NB) is:
knowledge, attitudes, beliefs, physical environment, access to food, food safety
In PES, E (etiology) is what?
the cause of the problem and contributing factors
Characteristics of etiology are:
-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”
T/F: Etiology may not always be clear.
T
What part of PES is this statement?
Excessive energy intake (NI-1.3) (problem) “related to” regular consumption of large portions at meals (etiology)…
E
What part of PES is this statement?
Swallowing difficulty (NC-1.1) (problem) related to recent CVA (etiology)…
E
What part of PES is this statement?
Unintended weight gain (NC-3.4) related to decrease in exercise following ankle surgery.
E
- The focus of monitoring and evaluation
- Defining characteristics
Are P, E, or S?
S (signs and symptoms)
What are the characteristics of signs and symptoms?
- Evidence that a problem exists
- Multiple examples make stronger statements
- Linked to etiology by words “as evidenced by”
Evaluation and monitoring of effectiveness of intervention is done by reviewing what?
Signs and symptoms
Etiology usually __________ the intervention.
Guides
T/F: It’s ok to guess the etiology.
F
T/F: “Unknown etiology is acceptable terminology.
T
Which step of the NCP is this?
- Determine intervention and prescription
- Formulate goals and determine action
- Implement action
NCP Step 3: Nutrition Intervention
Which step of the NCP is this?
- Select or identify quality indicators
- Monitor and evaluate resolution of diagnosis
NCP Step 4: Nutrition Monitoring and Evaluation
Define “evidence-based dietetics practice”
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.
Parts of a medical record include what?
- 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
What is EHR (Electronic Health Record)?
An integration of all medical documentation into electronic format.
What are progress notes?
- Daily updates entered into medical records
- May be in SOAP, ADIME, narrative, or other formats
T/F: Progress notes are entered by al members of the health care team.
T
T/F: Progress notes are not kept in chronological order.
F
What is a medical record?
A legal document of written documentation of the NCP, including interventions and activities used to meet the nutritional objectives.
HIPAA stands for what?
Health Insurance Portability and Accountability Act
PHI stands for what?
Protected Health Information
What is PHI?
- Written documentation from medical records (including paper and electronic databases)
- Spoken or voicemails info including voicemail messages
- Photographic images
- Audio and video recordings
Wrongfully accessing or disclosing PHI: fines up to $____________ and up to ______yr/s in prison.
$50,000; 1 yr
Obtaining PHI under false pretenses: fines up to $___________ and up to _____ yr/s in prison.
$100,00; 5 yrs
Wrongfully using PHI for commercial activity: fines up to $_______________ and up to ___ yr/s in prison.
$250,000; 10 yrs
T/F: HIPAA criminal and civil fines can be enforced against individuals as well as covered facilities.
T
T/F: A HIPAA violation could be grounds for immediate dismissal from your internship!
T
Nutrition Care Documentation is used for:
- Quality assurance
- Communication among the health care team
- Verifies care given
- Required for Joint Commission accreditation and state audits
T/F: All entries for medical record documentation can be written in any ink color or typewritten.
F only black ink
T/F: All entries for medical record documentation should include the date, time, and service.
T
T/F: Abbreviations are okay to use in medical record documentation.
F
The __________ _________________ has a list of forbidden hand-written abbreviations (the Do Not Use list) which have been associated with medical errors in the past.
Joint Commission
T/F: Medical record documentation should be done in advance.
F - it should be done at the time of service or procedure is performed
T/F: All entries for medical record documentation should be signed at the end and include credentials.
T
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.
T
ADIME documentation style
- Assessment
- Diagnosis
- Intervention
- Monitoring
- Evaluation
DAP documentation style
- Diagnosis
- Assessment
- Plan
PIE documentation style
- Problem
- Intervention
- Evaluation
IER documentation style
- Intervention
- Evaluation
- Revision
SAP documentation style
- Subjective
- Assess
- Plan
SOAPIER documentation style
- Subjective
- Objective
- Analysis/assessment
- Plan
- Intervention
- Evaluation
- Revisions
SOAP documentation style
- Subjective
- Objective
- Assessment
- Plan
An assessment presents all data pertinent to ________ decision making.
clinical
- Food/Nutrition-Related History
- Anthropometric Measurements
- Biochemical Data, Medical Tests, and Procedures
- Nutrition-Focused Physical Findings
- Client History
Are all examples of what?
Assessments
A nutrition diagnosis includes a _____ statement.
PES
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?
Diabetes
What is the Medical Dx of:
Increased energy expenditure (NI 1.1) related to trauma from MVA as evidenced by results of indirect calorimetry?
Trauma and closed head injury
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?
Inflammatory Bowel Disease (IBD)
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?
Obesity
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?
Anorexia nervosa
Intervention is what you recommend or plan to do to address the _________ __________.
Nutrition diagnoses
- Nutrition education (E)
- Nutrition counseling (C)
- Coordination of nutrition care (RC)
Are examples of what?
Intervention
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____________
subjective
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_____________
objective
