Exam (elaborations)
CLINICAL ORIENTATION QUESTIONS WITH COMPLETE ANSWER1.
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CLINICAL ORIENTATION QUESTIONS WITH COMPLETE ANSWER1.
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CLINICAL ORIENTATION QUESTIONSWITH COMPLETE ANSWERS
What bbis bbthe bbpurpose bbof bbdocumentation? bb- bbAnswerTo bbinform....
-the bbcare bbthe bbpt bbis bbreceiving
-treatments bband bbcare
-care bboutcomes
What bbquality bbassurance bbmechanisms bbare bbassociated bbwith bbdocumentation? bb-
bbAnswerPerformance bbreviews
Audits bb& bbaccreditation
Legislated bbinspections
Critical bbincident bbreviews
What bbare bbthe bb10 bbC's bbof bbdocumentation? bb- bbAnswerClear
Concise
Consecutive
Correct
Contemporaneous
Complete
Comprehensive
Collaborative
Confidential
Centered bbon bbpt
How bbsoon bbmust bbnutritional bbscreening bbbe bbcompleted bbafter bbadm? bb-
bbAnswer24 bbhours
According bbto bbArkansas bbState bbHealth bbDept. bbwhat bbmust bbthe bbnutrition
bbevaluation bbinclude? bb- bbAnswer1) bbpt bb% bbof bbgoal bbbw bbrange
2) bbabnormal bbpertinent bblab bbvalues
3) bbkcal bband bbprot bbneeds
4) bb% bbof bbfood bbintake bbsince bbadm
5) bbabnormal bbintake bbor bbrecent bbintake bbbefore bbadm
6)objective bbevaluation bbof bbpts bbcompliance bbwith bbphysician bbordered bbdiet bbbefore
bbadm
7) bbfood/drug bbinteractions
8) bbpt's bbspecial bbfeeding/nutrition/fluid bbneeds
9) bbpts bbfood bbpreferences, bbdislikes, bballergies, bbor bbintolerances
, According bbto bbArkansas bbState bbHealth bbDept. bbwhat bbmust bbbe bbincluded bbin bbthe
bbnutritional bbcare bbplan? bb- bbAnswer1) bbneed bbfor bbindividualized bbnutritional
bbcounseling
2) bbneed bbfor bbdischarge bbplanning
3) bbneed bbfor bbnutrition bbassessments bband bbclinical, bblab, bbsocial, bbor bbnutritional
bbdata bbto bbassist bbongoing bbevaluation
4)need bbfor bbf/u bbcare bbto bbevaluate bbnutrition bbregimen
5)requests bbto bbphysician bbfor bbalterations bbin bbdiet, bbnutrient bbcontent,
bbadministration, bbor bbmeal bbpattern
When bbmust bbf/u bbnutritional bbcare bbbe bbprovided bbif bbpt bbis bbat bbnutritional bbrisk? bb-
bbAnswerevery bb72 bbhours
If bbthe bbpt bbis bbstable bbwhen bbmust bbf/u bbnutritional bbcare bbbe bbprovided? bb-
bbAnswerevery bb7 bbdays
What bbmust bbbe bbincluded bbin bbf/u bbdocumentation? bb- bbAnswer-Evaluation bbof
bbeffectiveness bbof bbthe bbprescribed bbnutrition bbregimen
-Changing bbnutritional bbneeds/status
-Nutritional bbcounseling
-Other bbrecommendations bbto bbimprove bbpt bbcare
What bbmust bbbe bbincluded bbin bbnutritional bbcounseling bbdocumentation? bb- bbAnswer-
Description bbof bbindividual bbnutritional bbcounseling
-Objective bbevaluation bbof bbpts bbunderstanding/ability bbto bbfollow bbdiet
-Plans bbfor bbcontinued bbcounseling/recommendations bbfor bbphysician bbfor bbdischarge
bbdiet bbcompliance
What bbare bbthe bbparts bbof bbthe bbmedical bbrecord? bb- bbAnswerdemographics
orders
medical bbhistory
H&P
progress bbnotes
test bbresults
interdisciplinary bbnotes
other bbinfo
What bbare bbpt bbdemographics? bb- bbAnswernon-medical bbinfo
identifying bb#'s, bbaddress, bbcontact bbinfo
race, bbreligion, bboccupation
health bbinsurance
emergency bbcontacts
What bbis bbmedical bbhistory? bb- bbAnswerSurgical bbhistory
Medication bband bbmedical bballergies
Family bbhistory
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