Documentation & Health Records Flashcards

In a SOAP note, where would a dietitian record a resident's report that 'food tastes bland'?

Answer: Subjective

Statements reported by the resident or family belong in the Subjective section.

Which of these is the best-written nutrition PES statement?

Answer: Inadequate oral intake related to dysphagia as evidenced by intake of less than 50% of meals for 7 days

A good PES statement names a nutrition problem, a specific cause, and measurable signs or symptoms.

When no state law applies, federal rules (42 CFR 483.70) require a nursing facility to keep resident clinical records for an adult for how long after discharge?

Answer: 5 years

Federal regulation requires keeping adult resident records for 5 years from discharge when no state requirement exists.

A dietitian copies and pastes last week's assessment into today's note without changes. What is the main documentation risk?

Answer: Outdated or wrong information is carried forward, weakening the record's accuracy and legal defensibility

Cloned documentation can spread errors and may not reflect the resident's current status.

Which document is a set of actionable medical orders on life-sustaining treatment, including artificial nutrition, that follows the patient across care settings?

Answer: POLST/MOLST form

POLST forms are signed medical orders that cover preferences such as tube feeding and transfer between settings.

Which electronic health information exchange standard supports interoperable sharing of nutrition data, such as diet orders, between EHR systems?

Answer: HL7 FHIR

HL7 FHIR defines resources, including NutritionOrder, for exchanging clinical data between systems.

When documenting a telehealth nutrition visit with an older adult, which element is essential?

Answer: The visit modality (audio-video or audio-only), patient location, consent, and participants

Telehealth notes must record modality, locations, consent, and who took part to support compliance and billing.