Documentation Standards Flashcards

In ADIME documentation, which section contains the nutrition diagnosis written as a PES statement?

Answer: Diagnosis

The Diagnosis section holds the PES (Problem, Etiology, Signs/Symptoms) statement that names the nutrition problem.

An athlete reports, "I feel exhausted by the second half of practice." Where does this belong in a SOAP note?

Answer: Subjective

Statements the client reports, such as feelings and symptoms, are recorded as subjective data.

Which entry is the best example of objective data in an athlete's nutrition record?

Answer: Body mass decreased 1.8 kg from pre- to post-practice

Objective data are measurable, observable values such as body mass change.

A practitioner makes an error in a paper chart. What is the accepted way to correct it?

Answer: Draw a single line through it, write the correction, and initial and date it

A single line keeps the original entry readable while documenting who changed it and when.

Which goal is written in SMART format?

Answer: Consume 20-25 g of protein within 2 hours after each training session for the next 4 weeks

This goal is specific, measurable, achievable, relevant, and time-bound.

Under HIPAA, which is an example of protected health information (PHI) when held by a covered entity?

Answer: An athlete's name linked to their lab results and diagnosis

Individually identifiable health information held by a covered entity is PHI.

When documenting a sports nutrition consult, why should vague terms like "ate poorly" be avoided?

Answer: They are not specific or measurable and can be misinterpreted

Specific, quantifiable language makes records accurate, defensible, and useful for follow-up.